Wednesday, 5 August 2009

Today's Battle

Over at the Canada Free Press.:
When asked by Senator Orin Hatch (R-UT) whether President Obama’s proposed socialized healthcare plan will mandate taxpayer funded abortion, Senator Barbara Mikulski (D-MD) admitted that it will require “any service deemed medically necessary or medically appropriate.” It now appears that the plan’s “medically appropriate” umbrella is far more expansive than most Americans could have imagined.

In addition to abortion on demand, the weight of the evidence indicates that cosmetic “gender reassignment” surgeries for both U.S. citizens and illegal immigrants who suffer from APA recognized “Gender Identity Disorder” (GID) may also be provided – free of charge – courtesy of the U.S. taxpayer. The current price tag for such a procedure can exceed $50,000.

Page 972 of the House version of the bill (H.R. 3200) provides for “standards, as appropriate, for the collection of accurate data on health and health care” based on “sex, sexual orientation [and] gender identity.” The Senate draft indicates that the government will “detect and monitor trends in health disparities,” requiring the Department of Health and Human Services to “develop standards for the measurement of gender.” (i.e., officially recognize subjectively self-determined “transgender” or “transsexual” gender identities). It further mandates ‘‘participation in the institutions’ programs of individuals and groups from…different genders and sexual orientations.”

Matt Barber, Director of Cultural Affairs with both Liberty Counsel and Liberty Alliance Action commented: “There’s a gulf of difference between what Obama and liberals in Congress, and the American people deem ‘medically appropriate;’ especially when it’s ‘we the people’ footing the bill. To force Americans, against their conscience, to fund abortion on demand and to facilitate gender confusion by subsidizing the elective practice of genital ‘sex-change’ mutilation is unconscionable.

“After hearing Sen. Mikulski’s ‘any service deemed…medically appropriate’ admission, I was prompted to dig a little deeper. I contacted the offices of Sen. Harry Reid, Rep. Charlie Rangel, Rep. Barney Frank and the House Subcommittee on Health. I asked, very simply, for ‘an assurance that the proposed healthcare plan will not allow taxpayer funded gender reassignment surgeries or hormone therapies.’ When faced with the bill’s relevant language, every staffer I spoke with either declined to answer or would neither confirm nor deny that such procedures would be covered.

Here's my reply:
I doubt sex reassignment will be included, too controversial.

It would make financial sense of course, we have the figures to prove it, but too many people find it all too icky.

Yes, it makes far more sense for taxpayers to not pay the 2c per year once for sex reassignment surgery, and to continue to pay 0.3-0.5c per year for 20, 30, or 50 years for all the drugs and psychotherapy to deal with the misery caused by not having it. Not financial sense, mind you, but it's a cost many are willing to pay.

Oh yes, and foregoing the additional tax revenue from having a functional, productive citizen, rather than a miserable, dysfunctional and desperately unhappy one. That's far more significant from a financial viewpoint, if we're talking about government-run healthcare.

OK, so it costs the taxpayer or insurance policy holder more over 5 years just in direct costs, and far more in foregone revenue. But there are significant savings in aged care, as so many die before they reach old age if they don't have it. It doesn't cost that much to ensure that trans people die, and many consider it a bargain at a few dollars a year in taxes, and a few cents in health insurance.

Every medical condition, from heart disease to hangnails, has a "Standard of Care", a "Best practice". Here's what the SOC for transsexuality says about genital reconstruction:

"Such a therapeutic regimen, when prescribed or recommended by qualified practitioners, is medically indicated and medically necessary. Sex reassignment is not "experimental," "investigational," "elective," "cosmetic," or optional in any meaningful sense.

Medically necessary. Not cosmetic. Not elective. Not optional.
But they're just medical specialists, what do they know?


Christine said...

no doubt these are the same people that would malign needle exchange programs on the basis that it forces tax payers to facilitate drug use... even though NE programs are shown to greatly reduce the spread of diseases like HIV & Hep C. A single case of HIV costs about $385,000 for lifetime treatment. A needle exchange program costs about that same amount
to run in a moderately-sized city so if they prevent even 1 case of HIV in a year they are actually turning a profit. The cost of Hepatitis C on the other hand can run well over $1M to treat over the course of a lifetime, so if a NE program prevents 10 cases of Hep. C then there is a substantial profit to the tax payer, yet here in Texas it is still illegal for medical professionals to fight diseases in this manner.

We shall see what happens.. I am hopeful that the winds of change are on their way TGs in the US.. A lot of pundits are speculating that the "Party of God"-style right-wing conservatism is on it's way out and that although we may end up with a more fiscally conservative government in 2012 or 2016 that in order to win Republicans will have to leave some of their old social hangups at the door. I am certainly hopeful -- sometimes you have no other option.

Penny wise - Pound stupid.


Anonymous T-Girl said...

This kind of thing makes my heart ache.

It always seems to tease, with no real chance of ever becoming reality.

So close. So far away.

Carolyn Ann said...

Your dialog assumes that payment for gender reassignment is a morally correct thing to do.

Is it?

I'd agree that gender reassignment should be part of an overall health plan - a reasonable Supreme Court would also agree (the Roberts Court is not usually described as "reasonable"). Unfortunately, the transgender community has two hurdles to cross:

1. "Government run health care" is an anathema. When people still say, with sincerity, "keep the government out of Medicare" there's more to the debate than morally obliged care.

2. It's been mixed in with abortion - the legendary third rail of American politics. Americans will, and have been proven to, vote against their own financial interests whenever abortion gets introduced. Like it or lump it - the right wing has stirred the two together. Beyond that - the right is slowly accepting that they lost the "gay debate". Who's next? The transgender community. That's not horrible - it's an unfortunate reality.

I could argue that the transgender community is not helping itself with health care. I could also add the issue that many Americans really do want a say in how their tax dollars are spent. Don't forget - it's one of the few places where you can readily ask what the local government budget actually is. (Britons get two days a year to ask; I'm not sure about Canada and Australia - I've never been able to find local budgets for those nations.)

One other factor is that Americans are leery of the government being involved in almost anything. Rightly or wrongly (I think such suspicion to be perfectly marvelous, even if it does promote debates some would rather not have), many Americans distrust the government to act in their best interest. Arguably, Bush, etc promoted that idea. Heck, it was a central idea of Reagan's administration. Some even credit him with coming up with the idea! Personally, I think William Buckley fostered it in the National Review. Barry Goldwater latched onto it, but Republican thinking is not the topic of this discussion.

People do not perceive government run health care as a good thing. When some in the TG community insist upon ideas that are not universally accepted - there are those who are more than willing to turn those notions against the greater good. Not because they have better ideas, but because they simply don't want people like President Obama to win.

It is not a moral issue - it is a political issue. It is a monetary issue. It is a "I don't like this much change in my lifetime" issue. It is about the old saw about the builder: he's willing to try new ways of building. As long as his father tried them first. Some people have definite ideas about morality, and what the government should be spending money on - should they be denied their objections, because others find them offensive? Inconvenient?

It is not up to the transgender community in America to get in a huff about the latest political attack upon their freedoms and rights. It is up to the American transgender community to demonstrate why such spending should be included. Rightly or wrongly, if the American TG community gets on its high horse and insists - they will have lost the debate.

I will also mention that you seem to have a distinctly anti-American bias of late. You're not being pro-Australian, unless such is being anti-American? I love this nation, imperfect as it is. Dissent, distrust of authority and askance glances at those whose who exercise power are part and parcel of America. Like I say, I love this nation, imperfect as it is. Please point out a more perfect nation, and I will be happy to point out why it isn't. If that is jingoistic, so be it. I've lived here for 20 years and have travelled across it in a way very few ever accomplish. It's not for nothing I love this nation, and it's not for trivial reasons either.

I will pose this question: who deserves the dollars more: the curable cancer victim, or the person who needs gender reassignment.

Darned morality. Gets in the way of simple answers, doesn't it?

Carolyn Ann

Carolyn Ann said...

Oops. Somehow, at the end of my argument about government involvement, I deleted a sentence that said: "Skepticism of government is an intrinsic and essential part of the Constitution, and was merely purloined by the right wing." I could add "who seem to do a marvelous of job of misinterpretation, being flexible in any interpretation and finally contorting the very idea to suit their ends. And that was just William Buckley! Goodness knows what a person could do with Reagan's philosophy, or Bush Jr's.

Carolyn Ann

Zoe Brain said...

With the money you save by providing SRS, and so not having a continued drain on medical expenses over many years, you could save the cancer patient too.

The problem is that it *is* politicised, and people would rather spend more health dollars in the longer term to *not* provide SRS than to save cancer patients.

Emelye Waldherr said...

"I will pose this question: who deserves the dollars more: the curable cancer victim, or the person who needs gender reassignment."

If I may rephrase: who deserves the dollars more: the curable cancer victim who smoked tobacco for 45 years, or the person who needs gender reassignment because they were born with a brain structure that doesn't match their physical sex?

Your question seems to assume that GRS is an elective procedure, or at least less necessary that cancer treatment. I find this assumption to be faulty. For some people, cancer treatment is unnecessary, usually because of their age or other more quickly terminal conditions. The same is true for GRS. Some trans people can do without, some with little or no consequence, others with more. But some transsexual people's survival is dependent on getting surgery.

My point is that I don't think the government is the correct entity to make this decision. It should be between the patient and their medical professional.

Carolyn Ann said...

While you're determining whom should get care, Emelye, perhaps you should consider that cancer comes in many forms?

What money would be saved, Zoe? What are the long term costs of not providing SRS? Anti-depressants and therapy? Is that what you're saying? Is society obliged to continue funding those, for an individual, in perpetuity? You fail to understand what the problem is if you think that. It isn't about denying SRS - it's about denying access to anything that will help those who need SRS. Drugs and therapy included.

While it might be proper for society to pay some of the costs of SRS, is it appropriate for society to shoulder the entire burden of the surgery, etc. What is the societal obligation? The cost of wigs? The cost of voice conditioning? Feminization surgery? The cost of makeup lessons? (No, that is not a facetious question.)

Personally, I would argue that if SRS is the road to happiness, then it is up to the individual to pay for it. It is not the job of society to fund the pursuit of happiness. Society simply must not stand in the way of such efforts. (Criminal attainment and use of hormones, etc, notwithstanding.)

Like I said - it's no use getting on a high horse about this. Demanding SRS as a moral right will ensure it is noticed - and denied as part of a political horse-trade. (Look at what happened with hate-crime definitions.) Answering the question why it is important to fund SRS as opposed to providing cancer care is not about rhetoric. It is about ensuring that the public health system provides the services it should. It's also about being able to respond coherently to questions posed by those who would deny the transgender the right to exist.

Answer that question - and I have a feeling some of the other questions about what America's health care reform can deliver for the truly gender dysphoric will also be answered. It's too important for the usual indignation and shrill denunciations. If it's not addressed, somehow, it will likely take a Supreme Court decision, and a long, long time before a publicly funded health system in America will fund SRS. No matter how strongly people feel it is their right to such a process.

The Supreme Court, a few years ago, ruled that receiving appropriate care for cancer isn't a right. In such an environment it becomes very difficult to argue that SRS is a right, and that the public has a duty, and obligation, to pay for it. That's not being transphobic, that's simply acknowledging the effort that is probably required to ensure that at least SRS is not denied.

So, which is more important: someone's SRS, or that young cancer patient?

Carolyn Ann

Boo said...

Carolyn Ann-

which is more important: a cast on someone's broken leg, or that young cancer patient?

A shower chair for one of my residents who can't stand for very long, or that young cancer patient?

Expensive AIDS cocktail drugs, or that young cancer patient?

That middle aged cancer patient, or that young cancer patient?

News flash: ALL healthcare is expensive.

Now setting Carolyn's high horse aside, the other serious danger here is that we could end up with Clarke-style gatekeeping impeding access to transition procedures.

Carolyn Ann said...

I'm not convinced you understand what I'm asking, Boo.

Carolyn Ann

Boo said...

I'm not sure you're asking a question you actually want answered, Carolyn Ann.

Carolyn Ann said...

Oh, but I am!

The question is not directly answerable - that's all. It's simply a variation of the old "blow up the world (killing everyone) or I'll kill the child" moral "quandary".

I'll restate it in a different fashion:
- Does anyone have the right to SRS?
- If so, who has the obligation to pay for that surgery?
- Considering that the Supreme Court has ruled that denial of care on financial grounds is perfectly reasonable:
- If premiums are capped (meaning money is restricted), what are the implications?
- Is society obliged to provide care and services for conditions that are not immediately life threatening, over those that are? (It currently doesn't have any such obligation)
- Is society morally obligated to provide SRS in a responsive manner, or can it legitimately delay treatment of transsexuals? (Perhaps they'll just pay, themselves?)
- Is it legitimate to pose the dilemma?

Like I said: which is more important - the person wanting/needing SRS, or a person hanging onto life because of some horrible cancer?

(I am being deliberately evocative in the wording, by the way.)

You also reiterated my point re the potential danger. Now, which is the greater problem (this is not a rhetorical question): the denial of abortion coverage, or the delay/denial of SRS? I will argue that denial of abortion is the greater problem for society. Simply put, there are more women seeking abortions than individuals seeking sex changes. Abortion as a right is guaranteed by Roe v Wade - there is no such case law for SRS.

How does the American transgender community address these issues? Answer those questions? I don't know. What I do know is that I don't see anyone asking them.

What I do see are inane conversations about introducing new, untested, unsupportable, concepts into the English language. I read a lot of justified anger about the violence and abuse transgendered people seem to endure. I do not see anyone paying that much attention to these questions. It's almost as it's assumed the TG community will either get tossed aside, or it's assumed that coverage will be there.

I don't know the answers, but I do know the questions will be asked. There is plenty of time for those who oppose the transgendered (for whatever reason) to both raise and exploit the issue.

That's my point. Simply because the TG community says SRS is needed, and the medical community agrees, it seems to be assumed that it will be covered.

So let me put it this way:
Can you wait another year for SRS, or are you going to take the funds needed to keep that cancer patient alive?

It really is not a literal question - but it does become one when it's phrased like that. And therein lies the real danger.

Carolyn Ann

Christine said...

The problem is that you seem to have constructed a False Dilemma. In reality both the cancer patient & the transgender patient can be treated. It seems like the UK seems manage both at the same time just fine (even if the wait times for SRS can be lengthy.) In the end though, the costs for either never really turn out to be nearly as high as you would expect.

For example, my husband has been fighting lung cancer this year & i've seen the invoices. The doctors claim unbelievably high fees for his treatments, but they know exactly how much the insurance is willing to pay, so usually about half of it gets adjusted out on the physician's end, insurance pays the other half and then we pay a $50 co-pay. I seriously doubt that single-payer healthcare will bring about the end of insurance adjusters. So like I said, both can be treated because nothing is really as expensive as it seems.

Carolyn Ann said...

I am, sincerely, sorry to hear about your husband. My grandfather died of lung cancer.

So what you're saying is that the economic issues outweigh the moral ones? What happen if there are no economic issues - because it turns out that providing SRS coverage is against the law? Because this is not a "beg forgiveness" situation - there's a very real danger that providing uncovered care could result in someone (the doctor) going to jail.

Carolyn Ann

Christine said...
This comment has been removed by the author.
Christine said...

I've read your posts but I still fail to see the "moral issues." Would it be immoral for society to provide treatment to schizophrenics? What about to soldiers coming back from combat who have PTSD? The SOC is pretty clear that SRS is not elective or optional, but rather is medically necessary. Just because some people attach an "ick" factor to it does that make it any less medically necessary? The majority of the 300,000+ troops who have suffered traumatic brain injuries(TBI), a large number of those PTSD, have NOT gotten treatment for more or less the exact same reason, inside their peer group it is considered shameful to seek treatment for PTSD so they never get it.

It seems to me that 2 wrongs do not make a right.

Carolyn Ann said...

I'm sorry - you've lost me. I've been arguing nothing but moral issues, and you're telling me I'm not arguing morality?

I wasn't trying to be exhaustive in my comparisons, either. Surely you could grasp that?

Apologies for the delay in getting back to you, Christine. I've had quite a busy weekend.

Carolyn Ann

Anonymous said...

It's simple. "Transsexuality" is a birth defect with a known cure. If you are against fixing birth defects, then you have an argument. If you aren't, then you are laboring under a misconception of the topic.

What you may be thinking of is the made-up nonsense of "transgenderism". This "condition" occurs when somebody doesn't like society's defined gender roles and tries to find a political identity to justify their behavior.

It's unfortunate that the two separate things have become mixed up. It leads people to attack surgery for transsexuals as unnecessary, because they believe it is about men wearing women's clothes.

Scientists know that variations occur in animal populations. Humans are animals. Therefore variations occur in humans. I don't think there is a counterpoint to that argument.

Carolyn Ann said...
This comment has been removed by the author.
Carolyn Ann said...

For the last time: I am NOT arguing my own view here.

That's why the questions are rhetorical, and pointed - and all but impossible to answer. It's a strawman argument. I didn't want to be explicit about that, but I guess I will have to be.

I had a vague idea that perhaps I could force some thinking about health care reform and the transgender community. So that when it comes up, there are some people who have thought about it, and maybe have come to some answers. I don't know the answers (I've said as much a few times). But it strikes me that the responses have assumed a de facto, agreeable, position. Nothing is further from the truth.

There are groups out there who are seeking to derail any health care reform because they don't like that it contains provisions for abortion. Something I see an absolute need for. Others don't.

There are also a couple of groups who are trying to get gender treatment removed.

Thinking back to the hate crimes fracas - it's entirely possible that transgender treatment will be dropped, in some political horse-trading.

Now, I can't participate directly in US politics. Although I live in New Jersey, I am not a citizen. As such, my personal ethics bars me from anything but commentating - I will not directly influence a national political discussion if I not a citizen of that nation. I will not work for political candidates. Nor will I contribute money.

My apologies for wasting your time. I will endeavor to restrict my commentary to my blog. I have no idea how successful I will be, but I'll try.

Carolyn Ann

EDIT: This is a rephrasing of the comment I deleted.

pe1biv said...

Carolyn Ann, there are a lot of medical conditions that are not life threathening, but where correction would be funded without anyone having a problem with it.
I have friends that suffer from a condition where there is nothing they can or could have done about it, bu because we can not use a simple test to see if it is real, you think these people should just fund surgery themself to improve the quality of their life?
Isn't that pure hypocritical?

Just like you and I know who we are and that our personality can not be changed, doesn't mean that with my friends this is different and that for them they did choose who they are?

It's not a mental illness, but just another variation on the intersex condition, even though you most likely would only accept the physical, clearly visible variation on the sex binary, as true and valid.
For many years our society, in cooperation with the medical profession, has been correcting physically intersex children to what THEY think the kid should be, without letting these children have a say!