Multiple perspectives on transgender-related medical costs


The Trumpenfuhrer’s pronouncement that he would like to get transgender-related medical costs off the military’s books has apparently changed the opinions of journalists:

  • CNN, July 31, 2015, “The high cost of being transgender”: “the Philadelphia Center for Transgender Surgery posts cost estimates for different procedures. Its price list mentions estimates of $140,450 to transition from male to female, and $124,400 to transition from female to male.”
  • CNN, July 26, 2017: the cost to provide transgender-related services to active military personnel would amount to 0.004-0.017% of the Defense Department’s total health care spending

(I’m not sure that the accounting in the second article is correct, incidentally. The “total health care spending” may include retirees and not simply “active military personnel.” (Forbes provides a breakdown of the $52 billion total that was spent back in 2012; note that this number is in the same ballpark as the entire military budget of Russia.) Also, the military historically has rejected recruits based on the possibility of being on the hook for long-term medical costs. “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden” says that ” Sex-reassigned persons also had an increased risk for … psychiatric inpatient care.” A Guardian article from 2004, “Sex changes are not effective, say researchers,” suggests that long-term psychiatry costs could be significant.)

[Since I’m not in the military and haven’t had gender-related surgery I don’t have a personal opinion on the merits of Trump’s proposed policy. I just think it is interesting that a statement by Trump has the power to effect such a dramatic change in point of view.]


Pilot perspective on the movie Dunkirk


Four of us, including two pilots, went to see Dunkirk last night. Since the historical story is well-known I won’t worry too much about spoilers.

Massive navy ships sink almost immediately after being hit by small bombs or torpedoes. Airplanes without engines, on the other hand, have near-infinite glide capability.

The movie is good at portraying the simple and non-redundant nature of the planes of the day, e.g., the Spitfire. But when a pilot is about to ditch in the English Channel, why doesn’t he take advantage of the near-infinite glide time to pull back the canopy and facilitate egress? There is also a pilot who has such great control of his aircraft that, after running out of fuel and thereby losing the engine, he can shoot down a German plane. After this heroic deed, however, he is unable to make a few turns such that he can land on the beach near the still-evacuating British and French soldiers. Instead he lands on a German-held beach (except that you wouldn’t know that the beach is held by “Germans” per se from watching the movie; the opposing forces are always “the enemy” and never “the Germans” or “the Nazis”).

The movie is about the individual experience of being in the midst of Dunkirk. There are no maps and there is no context provided. Nor is there the rolling text wrap-up at the end of the movie telling you what happened in real life. One friend complained that she was “confused” during the movie, but maybe that is the point. Being in the midst of a war is confusing, according to every first-person account that I’ve ever read.

Readers: what did you think?

[Separately, one member of our group had recently seen Valerian and pronounced it “the worst movie ever made,” based on the plot and acting. Who has seen Valerian and wants to comment?]

Self-driving sag wagon for bicycle touring?


If we ask the average person “Why don’t you want to take a long bike ride?” I would bet that two big concerns are the following: (1) lack of sufficient fitness, and (2) fear of being hit by a car.

I wrote Business idea: Luxury bike tours with electric bikes about how the latest generation of electric bikes, combined with a sag wagon full of spare batteries, could completely address Point 1. What if the sag wagon were a self-driving van, though? Could it address Point 2?

Suppose that the sag wagon follows 10′ behind the cyclist. The sag wagon has some big flashing hazard lights on the back. Approaching traffic has to slow down and swing wide to get around the sag wagon and therefore can never be in a position to hit the cyclist. The self-driving sag wagon contains spare batteries. The sag wagon is immediately available in case of mechanical failure, rain, fatigue, etc.

Readers: What do you think? Will self-driving minivans revolutionize bike touring?

Oshkosh 2017: the year of autopilots


About 15 years after the introduction of reliable inexpensive digital sources of attitude (is the aircraft pitched up or down?), a slew of new autopilots was announced at Oshkosh this year:

  • S-TEC 3100, from the company that made all of the Cirrus autopilots for the first 10 (pre-Garmin) years. This includes envelope protection (nudge the plane back towards a reasonable attitude if crazily pitched or banked, even while the pilot is hand-flying) and “straight and level” panic button.
  • King KFC 230 AeroCruze (they defrosted a marketing expert from the 1960s to name this thing?)
  • Garmin GFC 500 and GFC 600, which might be the most innovative: “Both autopilot systems drive servos manipulated by brushless DC motors and a gear train that eliminates the need for a mechanical slip clutch, both of which reduce maintenance and improve reliability and longevity.” (An avionics installer/maintainer told me that previous generations of Garmin servos/clutches were notable for requiring substantial annual inspections/tests, so it is unclear whether these work better than competitors’ legacy actuators or if they are simply better than Garmin’s legacy actuators.)

Note that these folks are mostly playing catch-up to Avidyne, which certified its DFC90 in 2012.

The ADS-B IN capability that most $100 million airliners won’t get until 2025 (or ever?) due to certification hassles is now available in a mass-market $200 version to use with your iPhone: Scout.

Separately, in this Year of Avionics, Dynon is certifying its inexpensive glass panel that has been limited to experimental (home-built) aircraft. A Cessna 172 from the 1960s can have a better panel than a new one with a Garmin G1000!

If you like things that run off electricity, why not run the whole airplane? Aero Electric seems to have revoked the laws of physics with a four-seat 2700 lb. (Cessna 172 is 2,400 lb. gross weight) battery-powered airplane with “four-hour endurance.” (With the technology of 2012, “Gasoline [had] about 100 times the energy density of a lithium-ion battery” (APS).)

No Oshkosh report is complete without mentioning Icon. They’ve delivered 6 out of 1800 airplanes ordered.


Greece is now so successful that it will be borrowing money to pay its bills


“Greece Looks to Turn a Corner After Years of Economic Pain” (nytimes) is interesting for what it tells us about how modern humans think about economic success:

The proposed bond sale, the details of which were released on Monday, offered hope…

Dimitri B. Papadimitriou, the economy minister, said his country was “getting out of a rut,” adding: “There’s an opportunity for Greece to become a normal country.”

The bond offering does not mean that Greece is out of the woods. It is just the first of several steps that Athens must take to test whether it can raise money in international markets to support its economy and government operations when the latest bailout, worth €86 billion, expires in August 2018.

Greece continues to stagger under a mountain of debt, which is now worth €314 billion. [As is typical for American media, the journalists can’t be bothered to put information into context. With a population of 10.75 million, this works out to about $29,200 per resident of Greece. Compared to GDP of $195 billion, this is just shy of 2 years of GDP.]

Quick summary of the article: “This country has been so successful lately that it will be borrowing money in order to pay its bills.”

(Maybe in fact the money is going to be borrowed to redeem old bonds that are coming due? But the article makes it sound as though simply borrowing is a sign of robust economic health!)

Immigrant to re-join the labor force


Latvian immigrant Angelika Graswald is on track to be released from jail by the end of this year: “Woman Pleads Guilty in Fiancé’s Kayak Death on Hudson River” (nytimes). Ms. Graswald came to the U.S. as an au pair, married and divorced twice at a profit, and was on track to receive $250,000 in life insurance proceeds from the death of her fiance and kayaking companion.

Perhaps one of the New York tabloids will use this headline idea: “Immigrant to re-join the labor force”.

Readers: Can she now collect the $250,000? She pleaded to “criminally negligent homicide.” Is there an exception in a typical life insurance policy that would bar her from collecting? Also, what will her profile say?


The denial of service attack that I launched on my own Dropbox


Who has used Dropbox with a large number of files?

I recently added 761,765 files of Android source code to my Dropbox (accepting a shared folder from a friend). This is only 60 GB (out of a 1 TB quota), but Dropbox has been unable to push any of my own new files up to the cloud. Currently it says “Indexing 463,243 files” and seems to be stuck there (though the number of files fluctuates so I know that it is still running).

Did I launch a denial of service attack on myself?

Baumol’s Cost Disease can explain U.S. health care costs?


In response to Government makes health care more expensive and therefore it is unreasonable to withdraw subsidies, a commenter wrote

Is the government responsible for Baumol’s Cost Disease?

Is the government responsible for extreme concentration of wealth?

The bulk of the problem is a lot simpler than you, Vance, and most others in the public square make it out to be.

Baumol’s Cost Disease says that industries with no productivity growth, such as string quartets performing live, have to compete for workers with industries that have high productivity growth and hire workers to write code for sticking ads into Facebook or press the “start” button on a fully automated factory.

“Drivers of health care expenditure: Does Baumol’s cost disease loom large?” is a 2012 paper by economist Carsten Colombier. He concludes that the effect is minor and mostly spending on health care has been “quantity-driven” (i.e., people are getting more tests and procedures, taking more drugs, etc.).

What about an informal analysis? “Obamacare Isn’t Stopping Doctors’ Incomes From Soaring” (Fortune, June 10, 2016) says

Far from flattening, as some Obamacare experts predicted, or even waxing in low-single digits like salaries for contractors, lending officers, beauticians, and most other workers, pay for doctors is surging.

Dermatologists, cardiologists, urologists, among others, are reaping double-digit increases that lift their salaries to the $500,000 a year range, and that’s not including substantial performance and signing bonuses, relocation allowances, and even full payment of their med school loans.

A system that fuels demand with huge subsidies, yet systematically restricts the supply, is a textbook formula for fast-rising costs. No illustration is more vivid than the problem with doctors’ pay, a category that accounts for 22% of all U.S. healthcare spending.

On average, family doctors got a $27,000 raise in the past year, from $198,000 to $225,000, for a 13% increase. Doctors in the two other primary care categories, internal medicine and pediatrics, also had great years. Each garnered 15% bumps to $237,000 and $224,000 respectively.

… general surgeons at $378,000 up 12%; dermatologists at $444,000. also up 12%; urologists at $471,000, up 14%; OB/GYNs at $321,000, up 16%; otolaryngologists at $403,000, up 21%; and non-invasive cardiologists at $493,000, which have seen their pay rise more than 30% above what they have been paid on average over the past three years. Orthopedists and invasive cardiologists also got inflation-beating increases of 4% and 5% respectively. On average, both specialties pay well over $500,000 year in salary alone.

[Note the spread between primary care and specialists. An American who has sex with a specialist earning $500,000 and collects child support should have close to the same after-tax spending power as an American who goes to medical school and works as a primary care doctor (works better in Massachusetts than Minnesota, though!). (The American (or foreign visitor) who has sex with two or three different cardiologists can have the same spending power as a cardiologist, if the state is chosen correctly.)]

If a fresh-out-of-training specialist can earn $500,000 per year by going to an “underserved” area of the country, how can we attribute this to competition with manufacturing employers? Intel gets tremendous productivity per worker out of its fabs, but how many Intel workers get $500,000/year?

If high salaries for people working in health care are primarily due to competition with other industries, why are those salaries going up at a faster rate than what other industries pay?

Nurses at one of our local hospitals are preparing to strike (Boston Globe):

Both sides agree that nurses wages’ at Tufts are below those of other Boston hospitals. Tufts officials say that they want to rectify that by offering a 10.5 percent raise over about four years to nurses at the top of the pay scale.

All other nurses would receive a 5.5 percent pay hike over four years, in addition to 5 percent annual step raises, which are already built into the contract.

The average pay for a full-time nurse at Tufts at the top of the pay scale is $152,000, according to the hospital.

Nurses are able to unionize and strike for higher pay, something that is unusual in the market portion of the U.S. economy. If patients would go to a cheaper non-union hospital rather than pay for these higher union wages, it wouldn’t be possible. So plainly there is some non-market factor in operation that makes consumers indifferent to the prices that this hospital charges and/or unable to go elsewhere.

Finally there is the patient experience. If we’re old we remember the days when seeing a doctor meant actually seeing the doctor and possibly a receptionist or nurse. Now the “doctor’s office” is stuffed with non-doctors embroiled in various paperwork tasks.

Readers: Can we relax and not worry that we spend 4X the percentage of GDP compared to Singapore or 2X compared to Europe on health care?



Government makes health care more expensive and therefore it is unreasonable to withdraw subsidies


“A Republican Health Care Fix” is a misleadingly titled yet still interesting article in the New York Times. (Misleading because, of course, the Republicans aren’t proposing to “fix” health care except maybe from the perspective of the health care industry, which will appreciate the continued flow of taxpayer cash, and also because the article itself doesn’t offer any proposed solution.)

One argument in favor of food stamps is that the government has a lot of programs that distort the market and drive up the cost of food. Having done this, it makes sense to provide food stamps (SNAP) to tens of millions of Americans so that their net food expenses return closer to what it would be if they could buy food at world market prices.

Health care is in kind of the same situation, J.D. Vance points out (thanks, Brian, for reminding me that I made the same point in March 2017). Government drives up the cost of health care and now tens of millions of Americans can’t afford the new distorted prices. Vance highlights things like FDA regulation keeping generic drugs costing 10-100X the world prices and the employer health care tax deduction distortion to the economy, but I think he misses parts of the bigger picture. For example,  the Feds generate huge inflation by running Medicare and Medicaid on a “just send us the bill” basis. The Feds and states restrict competition with all kinds of licensing requirements for both insurance companies and doctors (e.g., a qualified doctor from New York can’t simply start practicing in Nebraska next week and a New Yorker can’t buy insurance that is offered to consumers in Nebraska).


The “full repeal” bill is nothing of the sort — it preserves the regulatory structure of Obamacare, but withdraws its supports for the poor. The House version of replacement would transfer many from Medicaid to the private market, but it doesn’t ensure that those transferred can meaningfully purchase care in that market. … devising that vision [to fix some of the biggest disasters in U.S. health care] is impossible when we refuse to accept that the government bears some financial responsibility in solving a problem it helped create.


Feminism Is Leaving A Wake Of Unhappy, Unmarried, And Childless Women In Its Path?


A physician friend IMed me “Feminism Is Leaving A Wake Of Unhappy, Unmarried, And Childless Women In Its Path” (Daily Wire):

Feminists claim to promote the advancement of women and gender equality, largely via the promotion of so-called sexual liberation, but their movement is leaving a wake of unhappy, unmarried, and childless women in its path, a real problem feminists seemingly refuse to entirely address.

According to a recent study from Yale University researchers, liberated, college educated women are freezing their eggs because they can’t find a man to marry and have children with before their natural childbearing years expire. In the U.K., for instance, one in five women is childless when their natural reproductive years expires, as opposed to one in ten women a mere generation prior.

So what’s to blame for this onslaught of college-educated yet terribly empty women?

The short answer is feminism.

The article links to “Shortage of eligible men has left women taking desperate steps to preserve their fertility, experts say” (Telegraph):

Prof Marcia Inhorn, Professor of Anthopolgy at Yale University, said professional women found themselves losing out in a game of “musical chairs” because there were simply too few men of the same calibre to go around.

“There is a major gap – they are literally missing men. There are not enough college graduates for them. In simple terms, this is about an oversupply of educated women,” she said.

This ties in loosely to Why don’t I know any single men? (my 2016 post that attracted 112 comments).

My response to the doctor:

Are we sure that there isn’t a simpler explanation? In the typical U.S. state or the U.K., a woman exposes herself to a property division and alimony lawsuit if she marries a lower-income partner. Why would a woman want to work hard until age 50 so that her husband can sue her and get paid alimony every month to have sex with a younger woman?

Her answer:

Funny you mention it. Just met anesthesiologist who is 51 – had a stay at home husband for 26 years (despite his engineering and MBA degree)- learned 3 months ago that he was rotating from one 26 year old to another.

(Note that the husband’s behavior is economically rational in Massachusetts or New York, but not in alimony-free Germany.)

Readers: What do you think? Does the egg-freezing industry owe its prosperity to (1) the abstract concept of “feminism,” (2) the economics of family law (marriage would give a male partner a financial incentive to discard an aging wife in favor of younger women, thus contributing to America’s shift to polygamy), or (3) more women have jobs that they love and they are too busy with work to find a partner?

Some reader comments on the cited Daily Wire story:

[Michael Hecht] The only reason I’m willing to settle down now is that my ex’s already cleaned me out…

[Pat Healy] Or maybe it’s because a large percentage of the available young men out there are un-marriageable pieces of crap, hopelessly addicted to porn, marginally employed, and essentially unable to care for themselves, let alone a family. My two dating-age daughters would lean heavily toward this explanation.

[Sentry, who describes herself as “one of the women who missed the first round of marriage”] Marriage poses a very real risk to men. They know that if the marriage ends in divorce, they will be kicked out of their home, lose their children, and half their income (sometimes more, depending on the state) for a decade or two. They know that if they offend their wives, she can lie about them, get them arrested for abuse that never occurred, get them jailed, and use their children as hostages and weapons. [interesting because it shows a conventional yet outdated view of family law as presenting litigation risk only for men.]

[Andrea L] That actually depends where you are. I lived in a “no-fault” divorce state. My husband refused to work, was very abusive to me and the kids (I found out later he was supplying drugs to the neighborhood kids). My lawyer told me that because I supported him during the marriage, he would get the house, the kids, the cars and child support and alimony even if the kids testified against him. I would have to pay all the bills. …

[Groundhog Day, responding to the above] Congratulations to your excellent choice!!! I know, it’s not your fault. It’s the men. They always magically morph from the most gentle, loving and romantic fellow into this abusive, binge-drinking, drug-abusing, child-torturing and wife-beating monster the very moment you toss the bouquet to be catched by the next victim of patriarchy – which feminism is actually fighting against…

[Allen Simms] … it’s taboo to criticize the OBVIOUSLY terrible choices of women. Women are the gatekeepers of sex, for better or worse. If women stop producing children with losers we will have much fewer losers. For some reason we find it okay to say “well the guy shouldn’t be a scum bag” but its not okay to say “women should stop opening their legs for scum bags”

[MattSE] Who wants to marry a pushy, self-centered broad who will probably divorce you 10 years from now?

[Stefan Stankovic, responding to the above] Not to mention, who the h3ll would marry a woman who needs multiple hands to count her sexual partners? That is becoming extremely common in my age bracket (I’m 24), and I would NEVER setlle with such a woman.

[VE, responding to MattSE] Read up on hypergamy, it explains why women can’t find ‘desirable’ partners. Essentially you’ve got all women chasing the top 10-20% of men and the pool is dwindling due to feminism and it’s real world deleterious effects on men.

[YeahNope, in the same thread] Polygamy is already prolific, it’s just hasn’t been formalized. Just by observing social groups you can see the high status men have unofficial harems of women that “share”.

[konokonohamaru] Not to mention, the fact that they’re looking for “committed” men is just a huge inconsistency in their worldview. They throw out religion, traditional values, and any semblance of moral absolutism, and they expect someone to commit to starting a family with them? Why should anyone do such a thing?

[David] Too many western feminized women use the biased anti-male laws to basically engage in serial marriage as a form of prostitution. This gives them the social veneer of “innocence”.

[PaulMurrayCbr] It’s that for men, commitment means lifelong, and for women it seems to mean “I’ll live with you for four to ten years and then I’ll leave you and take your children with me”.

[JoEd, responding] You forgot half of your net worth. They will take that too.

[KnowManIsle, responding] More than half.

[EventHorizon] … the problem is far less contentious: poor planning. Two days ago this very topic came up with a coworker. She is a nice lady that certainly is not your argumentative 3rd wave feminist. When she complained about her misfortune of finding a partner in her early 30s, I asked her “Percentage-wise, how important are your career and your desire to start a family to your life?”. She said “50-50”. When I followed with “So how do you actually split your time between these goals?”, she replied: “90% towards my career” …

Some reader comments on the linked-to Telegraph story:

[Ken Mitchell] There are just as many men as always – but when women earn more, there are fewer and fewer men who make even MORE.

[Cad Ders] Feminism is already a dead woman walking. All feminism has is shaming language and the State (ironically, ultimately other men) to keep men to the feminist line. … increasingly, the shaming doesn’t work. And men are disengaging from society in general to avoid entanglements with the state; if you don’t get married, you can’t be divorced, if you don’t co-habit you can’t have half your stuff appropriated, if you don’t have children, you can’t be on the hook for child support, if you don’t enter the corporate world you can’t be be accused of ‘harassment’ and if you don’t date you drastically reduce your chance of a false rape accusation. These are genuine threat points for men in the modern world that didn’t exist before feminism. … As feminism reduces the value of women (in men’s eyes), so men are reducing the amount of time, effort, attention and money they are willing to spend for the declining benefits modern women now bring to their lives. …  the truth is that men don’t want to fight women, it goes against the core of what it means to be a man. But feminism thrust men into a fight that they neither started nor wanted. To the point that feminists are reduced to crowing about ‘winning’ battles that men never turned up for.

[Charles Blackson] There is no shortage of men of course. It’s simply female hypergamy in action. I take issue with the implication that these are high quality females though. Not the case. Rather they are life’s genetic dead ends. The only way you can possibly fail at life itself is to fail to have children. These females are literally evolutionarily unfit to pass their genes on to future generations.

[M’erica First] Let’s just call it like it is and not the BS spin that the author puts on this. Women are all about marrying someone that has money. … And if the marriage doesn’t work, then they get half of said money. … My father warned me against marriage, but I didn’t listen. I hope my son listens to me. I will do a much more thorough job of documenting the pitfalls to him. I hope he sees that I was simply a meal ticket, sperm donor and financial slave to his mom’s whims.

[Ian Noble] The marriage market has also been globalised and men can now find a thin, well-educated (but without a ridiculous sense of entitlement), attractive partner with good personal hygiene and an intact hymen who enjoys looking feminine and pleasing her husband. Such women are almost impossible to find in the UK and no amount of ‘marketing’ will change this fact – just as no amount of marketing could save British Leyland.

[Harry Beckett, responding] Yeah, but when you buy a Toyota it can’t wait a few years, get citizenship. divorce you, take half your stuff and then bring in the Japanese owner it really always wanted in the first place.

[FG Lorriman] Nature is sexist, and if any girl has any notion of having a family and children, they need to prioritise that. Sure, get the degree, but don’t shag your way through university; instead find clubs/guys who are looking to start families young. … women past about 30 are losing their looks and pudging or sagging rapidly. If they’ve been on the corporate/professional treadmill of hard hours, hard drinking and hard sh*gging, then you can pretty much forget it.

[Per Olausson] Social media. The commoditisation of sex appeal, status, looks and appearance. The assurgency of the political correct not just of opinions and politics but also who is acceptable to mate with. …  Just put the smartphone down and interact with people you meet. Maybe something will sparkle. Even if he is “beneath and not worthy” of you. It worked for your parents and grandparents.


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