Some International Stories to Read

In France, women are protesting sexism. The Strauss-Kahn case has served as a lightning rod.

On the other hand, in Malaysia the police are alleged to have chained and branded foreign women suspected of prostitution. Do read the excuses at the end of the piece for their pitiful nature.

For really nice news (from some days ago) about all those women who can't do physics and don't want to, either:

A 22-year-old Australian university student has solved a problem which has puzzled astrophysicists for decades, discovering part of the so-called "missing mass" of the universe during her summer break.
Undergraduate Amelia Fraser-McKelvie made the breakthrough during a holiday internship with a team at Monash University's School of Physics, locating the mystery material within vast structures called "filaments of galaxies".

Feminine Tosh?

That's the opinion of the Nobel-price winning author V.S. Naipaul on women writers:

Nobel-prize winning author V.S. Naipaul claims that there is no woman writer who could serve as as his literary match. Described by some as “the greatest living writer of English prose,” the Trinidad-born Naipaul sparked controversy in an interview at the Royal Geographic Society this week, saying the work of female writers, even famed and beloved author Jane Austen, is inferior. The 78-year-old said he couldn’t share Austen’s ” sentimental ambitions, her sentimental sense of the world.”
Naipaul believes that women writers are “quite different” and says he can read a paragraph and know instantly whether it was written by a woman or not. He added: “And inevitably for a woman, she is not a complete master of a house, so that comes over in her writing too.”

What a Catch-22 there! Women are sentimental creatures not even in charge of their own houses. So no wonder they are second-rate writers.

Jane Austen's sense of the world is sentimental?

It is a truth universally acknowledged, that a single man in possession of a good fortune, must be in want of a wife.

I do not want people to be agreeable, as it saves me the trouble of liking them.

A large income is the best recipe for happiness I ever heard of.

Nothing amuses me more than the easy manner with which everybody settles the abundance of those who have a great deal less than themselves.

For what do we live, but to make sport for our neighbours, and laugh at them in our turn?

We met Dr. Hall in such deep mourning that either his mother, his wife, or himself must be dead.

In all the important preparations of the mind she was complete: being prepared for matrimony by an hatred of home, restraint, and tranquillity; by the misery of disappointed affection, and contempt of the man she was to marry.

Naipaul is a sexist. And a pretty poor reader, it seems.

A Few Weeks In the Life of a Wingnut Governor: Rick Scott, a Ringwraith.

That would be Florida governor Rick Scott. My, what a busy beaver he is! He has managed to turn large chunks of the Medicaid system to for-profit health care providers:

Florida Gov. Rick Scott signed two historic Medicaid bills Thursday, placing the health care of nearly 3 million Florida residents into the hands of for-profit companies and hospital networks.
Lawmakers said the program was overwhelming the state budget and needed to be privatized to rein in costs and improve patient care. Critics fear the bills build on a flawed five-county experiment where patients struggled to access specialists and doctors complained the treatments they prescribed were frequently denied.

Medicaid pays for the health expenses of certain groups of the poor but it also covers 60% of all nursing-home care for the elderly in this country. Many of those elderly were not poor until they spent down their own funds.

So it is pretty fascinating that the privatization will begin with the latter group:

Long-term care patients will be the first to enroll in the statewide program starting in October 2013. The rest of the population will join the following year. The developmentally disabled population will not be included in the privatization program and will operate for three years under an 'I Budget,' which offers patients more flexibility.
Those seniors were not included in the original part program "because everyone knew they were too frail," said Rep. Elaine Schwartz.
"Extra vulnerable seniors who do not have the stamina to struggle with the Medicaid web of claim denials that HMOs practice should not be the first to be thrown under the bus, state-wide," said Schwartz, a Democrat from Hollywood.

I have not kept up with the research that studies quality of care in nursing homes but when I did follow that field the for-profit nursing homes had more problems than the not-for-profit nursing homes.

But wait! There is more! Rick Scott also signed into law new abortion restrictions:

House Bill 97 removes coverage for abortions in health care insurance exchanges created by federal health care reform. The law provides exceptions for cases of rape, incest and a threat to the woman’s life.

AND he cut funding for the care of at-risk infants. I'm not kidding you:

Last week, Gov. Rick Scott signed the state’s budget, which proposed reductions to health services for women and children. He also vetoed millions more in health service projects set aside specifically for women and children. Programs that aim to lower infant mortality and increase women’s health in the state have seen a major setback since Scott took office.
Among the many vetoes from last week: a program that would add a test for Severe Combined Immunodeficiency Disease, or SCID, to the list of genetic diseases newborns are tested for in Florida.

There you go! Unborn children are valuable but once they are born children Rick Scott does not care. Neither does he care about the elderly or the poor.

At The Freedom And Faith Conference

Republicans have gathered together to appeal to the social conservative base of the party. "Social conservatives" is a (an?) euphemism for people who want gays and lesbians in the closet and womenfolk in the kitchen. "Freedom and faith" are also tricky concepts here, given that others don't exactly push for a world full of prisons and a ban on all religions. Come to think of it, the "freedom and faith" bunch meeting right now do like prisons and seem to have a clear preference for fundamentalist Christianity. They also declare that they own god.

Whatevah, as all blaze political writers say. Former Utah Governor Jon Huntsman spoke at the conference to explain how he is all for freedom and faith:

"As governor of Utah I signed every pro-life bill that came to my desk," Hunstman told the crowd. "I signed the bill that made second-trimester abortions illegal, and increased the penalty for doing so. I signed the bill to allow women to know the pain an abortion causes an unborn child. I signed the bill requiring parental permission for abortion. I signed the bill that would trigger a ban on abortions in Utah if Roe v. Wade was overturned."

Perfect Teamwork

Eleanor Powell and Fred Astaire

On The Latest Arizona Shootings

A man killed five people and gravely wounded at least one additional person:

The shooting spree "stemmed from a divorce situation," Yuma Police Chief Jerry Geier said. He declined to give details.
Police identified the shooter as Carey Hal Dyess, 73, of Yuma. Dyess shot six people, killing five and gravely wounding another, before he killed himself, Yuma community relations director Greg Hyland said.

There are several questions this horrible event elicits, having to do with intimate partner violence, access to guns and so on. But it also links to something I think I may have noticed recently: Murders or killings carried out by men in this particular age group seem to be growing more common.

This may be a misconception. Does anyone here know what the statistics of homicide are by the age of the perpetrator?

Fluff Post For the Day

Because I have been running errands, including the filling-in of a zillion forms. I hate them but actually don't really mind bureaucracy, because without some such system the weaker ones will lose even more.

But the fluff is not about that. It's about to-do-lists. I use them all the time but even so I realized that mine are fairly undeveloped. For instance, it's not a good idea to put down eighty things to do for tomorrow, because even the ten one manages to actually do will look like a failure afterwards. But I still put down far too many things, ranging from "sew button" to "fix the world."

And "send package to mom" is a disastrous number on that list. Much better to put down on one day: "gather together things for mom in one place," and on another day: "find a box of the right size," and on yet another day; "find tape and scissors", then: "prepare package," and finally: "mail package to mom." That way it gets actually done, and you feel full of achievement for a week.

Making An Army on Horseback Out of A Nail That Might be From a Horse-Shoe. Today's Science Critique.

Lots of research into the possible ancestors of modern humans does that. There is a find of something, but nobody can actually tell whether what was found represents a common aspect of the life of the studied hominids. The find consists of not much: A few bones or some remains of a possible camp-site or some fossilized footprints. Then one builds theories on that basis.

I'm not saying that the theories are necessarily wrong ones but we really have very little actual evidence, and most of that could lend itself to several different interpretations. Too often the suggested interpretations become what we learn from the research, not what it really, truly found.

Then the interpretations get further interpreted by our current popular culture. Or by earlier cultures; we still get cartoons about the "caveman" going out hunting while the "cave-housewife" stayed behind to mind the children in the "cave-nuclear-family."

A recent piece demonstrates all this. Note that it is not a bad piece of research, not at all. It is just limited by the problems I discussed:

That we really don't know how representative the few finds we have are, that most of the finds don't tell us much about the sociological frame for the find and that the numbers of finds are exceedingly few. In some ways it is as if an archeologist finds a nail which could have come from a horse-shoe and then slowly moves into the argument that an army with horses and riders must have traveled through the area.

Here is the study which started all these thoughts:

Ancient forerunners of modern men stayed close to where they were born but paired up with females from far beyond their local stomping grounds, a new study claims.
The research provides a rare insight into the social behaviour of primitive "hominins" that appears to match closely that seen in chimpanzees and bonobos today.
Scientists analysed fossilised remains around cave networks near Johannesburg in South Africa and found that while 90% of males appeared to have spent their whole lives in the area, at least half the females had come from farther afield.
The work suggests that males regularly stayed with the community they were born into, with females roaming into new territories as they reached sexual maturity, the scientists report in the journal, Nature.

This is the it-must-have-been-a-horse stage. The earlier stage, that of finding the nail from the horse-shoe, involved looking at the fossilized teeth of two extinct species to analyze the amount of strontium in them. Strontium levels may be linked to the area in which the individual grew up. The research found that:

The strontium tests revealed that most of the individuals lived and died in the same area, where the rock is dominated by a limestone called dolomite. But results from the smaller teeth, which most likely came from females, showed many must have spent their youth elsewhere.

This doesn't sound bad at all, right? But when you find that the percentages (90% of males, at least half of females) in the first quote above were based on EIGHT Australopithecus africanus individuals and ELEVEN Paranthropus robustus individuals you might begin to see the horse-shoe aspect of the problem. Only the Australopithecus africanus is regarded as a possible forerunner of modern humans, by the way. Thus, from one nail to a horse-shoe.

But the results are then interpreted to get that army on horseback:

"Here we have the first direct glimpse of the geographic movements of early hominids, and it appears the females preferentially moved away from their residential groups," said lead author, Sandi Copeland at the Max Planck Institute for Evolutionary Anthropology in Leipzig.
A similar situation is seen among modern chimpanzees, where females tend to move out of their groups, in part because males form strong ties that help them protect a troop's territory.
"By virtue of the fact that the males choose to remain, the females are indirectly forced to leave their communities in order to avoid close inbreeding. It could be that among these early hominins, female dispersal has some correlation to close cooperative behaviour between males," Copeland added.

Perhaps. Or the small teeth might not be female teeth at all. Or the females might have been kidnapped by the males from other groups. Or, as the title of the quoted piece suggests, perhaps females were the ones with the wanderlust? And where all these finds from roughly the same time period? From the same groups? Could it be that the teeth belong to different times and different groups?

Neither do we know anything about the cooperative behavior of the hominid males, or even whether the males "chose" to remain in the same communities.

The final round in the horse-shoe games always consists of the popularizations. The Guardian isn't really playing that game, even inserting a different interpretation by the choice of the headline. But think how the story would be interpreted if the findings had been that it was the male hominids who appear to have come from elsewhere.

The interpretation would not be about female cooperation as the reason for their dispersal. It would be all about man-the-explorer, and how that aspect of men explains their current dominance in various ways.

Women: 21. Governing Body: O (by res ipsa)

Hey, remember the female badminton players?

Well, they won one.

(I want to give you a nice little excerpt from the article, but Blogger isn't cooperating.)

Not only did the Badminton World Federation abandon the "Girls must wear skirts" rule, but they also say that future efforts to improve presentation of the game will include the men's game. No idea if one EOTS commenter's suggestion that men play in the nude will be considered.

Eric Cantor: The Authoritarian Head of the American Household

You probably know that House Majority Leader Eric Cantor (R-VA) wants federal aid to the tornado-struck Joplin, Missouri, to be matched with cuts elsewhere in the federal budget.

On CBS's "Face the Nation", Cantor elaborated on his views:

On Sunday, he compared the situation to that of a family putting off buying a new car when a family member became ill.
"When a family is struck with tragedy -- like the family of Joplin ... let's say if they had $10,000 set aside to do something else with, to buy a new car ... and then they were struck with a sick member of the family or something, and needed to take that money to apply it to that, that's what they would do, because families don't have unlimited money. And, really, neither does the federal government."

So Eric Cantor's imaginary family has no health insurance. Well, that is to be expected, given his earlier views on health care.

Comparing the federal government to families is often pretty misleading because governments are NOT families. They have different duties, for one thing.

But if we accept the metaphor, Cantor's imaginary family, with him in the position of the dictatorial decision-maker, seems to be doing something more than cutting back on other expenses because of lack of health coverage. It seems to be negotiating with its sick member about whether the money will be spent on the needed treatment in the first place.

Reader Appreciation Day

I love you people. You are smart, kind and mostly polite and teach me so much. So thanks very much for reading and commenting here.

Meanwhile, in Egypt: Not Like Your Daughter Or Mine

According to CNN, virginity tests were performed on arrested Egyptian female demonstrators after the March 9 protests:

At that time, Maj. Amr Imam said 17 women had been arrested but denied allegations of torture or "virginity tests."
But now a senior general who asked not to be identified said the virginity tests were conducted and defended the practice.
"The girls who were detained were not like your daughter or mine," the general said. "These were girls who had camped out in tents with male protesters in Tahrir Square, and we found in the tents Molotov cocktails and (drugs)."
We didn't want them to say we had sexually assaulted or raped them, so we wanted to prove that they weren't virgins in the first place," the general said. "None of them were (virgins)."

Well, that's OK then. Except that the rape excuse is a feeble one unless we believe that only virgins can be raped and that the raped women could somehow prove, after the rape, that they had been virgins before it.

The real intention behind this practice is clear: To make participating in demonstrators more dangerous and more humiliating for women. Then they will stay at home as they are supposed to do.
---
Via Jennifer Armstrong.

“Non sono una donna a sua disposizione!” (by res ipsa)

Translation: "I am not one of the women at your disposal.” --Italian politician, Rosy Bindi, to President Silvio Berlusconi, who is the subject of this jaw-dropper of a New Yorker article by Ariel Levy. At one point, Levy asks Marco Ventura, Berlusconi's coordinator for foreign press, if she can meet Berlusconi:

...Ventura thought for a moment and replied, “Would you consider having plastic surgery first?” It wasn’t so that I could look like a velina, he explained; he would feel better about arranging the meeting if I had my face messed up, because then there would be a better chance of the Presidente keeping his hands to himself.

Mamma mia.

On Memorial Day

This is what I wrote last year. It is still what I think about this day.

Meanwhile, in China, A Return to Mistresses As Status Symbols?

Having a mistress raises a man's status, especially if the woman is college educated:

Throughout China's dynastic history, keeping mistresses was not only tolerated, but actually had the official seal of approval from the men at the top. The country's emperors maintained legendary harems of concubines, as did noblemen, wealthy merchants and anyone seeking to enhance their social status. Indeed, the country's most famous classic novel, Dream of the Red Chamber, relates the story of an imperial concubine in the Qing dynasty who supports her entire family, including its own numerous concubines, thanks to the emperor's patronage.
That historical context has perpetuated the notion that having a mistress equates to having status and power. Now, in today's status-hungry China, keeping a mistress is once again the fashionable thing to do. In some cities, an entire ecosystem has sprung up to support the ernai industry. A recent online exposé revealed an ernai agency in Shanghai that provided a menu of potential college-student mistresses for men willing to pay. The annual maintenance fees ranged from just $3,000 for students in less renowned schools to about $26,000 for students from the best campuses. (See pictures of China on the wild side.)

I have no idea how common this phenomenon might be, but it seems that girls are now being educated in how to avoid becoming mistresses. As the end of the linked article notes, it would seem to make more sense to educate the men. Or to educate both sexes.

It's shocking how most of the communist countries return to very traditional views about women when allowed. As if no real societal change could happen while the government ruled everything. The people slept like The Sleeping Beauty, and woke up to roughly the mores and norms which prevailed at the installation of the communist system.

That was probably somewhat exaggerated. But sexism certainly thrives in several ex-Communist countries, still awaiting the Prince(ss) Charming of real feminism.

Never mind. What I really wanted to write about is the oddity of this whole mistress idea especially if it really has something to do with the idea of having multiple mistresses or a wife and a mistress.

Consider that China is a country with excess men, a problem which will only become worse in the future. The last thing that would seem to make sense under those circumstances is unofficial polygamy. There will be millions of men who can find no female spouse at all even without it.

Smiling Guys Finish Last

In sexual attraction, that is. I have been told this by at least eighteen Internet popularizations of a new study about emotional expressions and sexual attractiveness among heterosexual North American men and women. Here is the summary of the study:

This research examined the relative sexual attractiveness of individuals showing emotion expressions of happiness, pride, and shame compared with a neutral control. Across two studies using different images and samples ranging broadly in age (total N = 1041), a large gender difference emerged in the sexual attractiveness of happy displays: happiness was the most attractive female emotion expression, and one of the least attractive in males. In contrast, pride showed the reverse pattern; it was the most attractive male expression, and one of the least attractive in women. Shame displays were relatively attractive in both genders, and, among younger adult women viewers, male shame was more attractive than male happiness, and not substantially less than male pride. Effects were largely consistent with evolutionary and socio-cultural-norm accounts. Overall, this research provides the first evidence that distinct emotion expressions have divergent effects on sexual attractiveness, which vary by gender but largely hold across age.

The emotional expressions tested in the studies were shown by photographs, many showing the top half of a person, and were listed as a) a neutral expression, b) a smiling expression, c) a proud expression (head back and arms raised in the air or head back and arms akimbo) and d) an expression of shame (head bent forwards). In some cases photographs were rated by a panel of psychology students as expressing happiness, pride, shame or neutrality, without the arm positions and so on.

Leaving aside my thoughts of how we are creating a brand new science about people looking at photographs and how this relates to our overall lives, I should still notice that we cannot be certain if the expression of "shame" indeed looks like "shame" to the viewers or if the expression of "pride" registers just that in the viewers.

But that's not what I want to write about. It is how the studies are interpreted. An example (thanks to Jennifer Armstrong for this link):

Women find happy guys significantly less sexually attractive than swaggering or brooding men, according to a new University of British Columbia study that helps to explain the enduring allure of "bad boys" and other iconic gender types. The study – which may cause men to smile less on dates, and inspire online daters to update their profile photos – finds dramatic gender differences in how men and women rank the sexual attractiveness of non-verbal expressions of commonly displayed emotions, including happiness, pride, and shame.

...

Tracy and Beall say that other studies suggest that what people find attractive has been shaped by centuries of evolutionary and cultural forces. For example, evolutionary theories suggest females are attracted to male displays of pride because they imply status, competence and an ability to provide for a partner and offspring.
According to Beall, the pride expression accentuates typically masculine physical features, such as upper body size and muscularity. "Previous research has shown that these features are among the most attractive male physical characteristics, as judged by women," he says.
The researchers say more work is needed to understand the differing responses to happiness, but suggest the phenomenon can also be understood according to principles of evolutionary psychology, as well as socio-cultural gender norms.
For example, past research has associated smiling with a lack of dominance, which is consistent with traditional gender norms of the "submissive and vulnerable" woman, but inconsistent with "strong, silent" man, the researchers say. "Previous research has also suggested that happiness is a particularly feminine-appearing expression," Beall adds.

Note, first how the "expression of shame" became brooding! That's not what the study was calling it. The popularization changed something rather important, I think, and the whole "allure of the bad boys" is similarly tagged on. There was nothing in the studies (at least based on the draft I got hold of) which attributed any of the emotions to being a "bad boy."

That is an example of the slippage which keeps happening in these popularizations.

Now to something which is not slippage. The above quote argues that the expression of pride was preferred in men by women because it is linked to status and the ability to provide for the offspring. But then how do the researchers explain why women, especially younger women, rank expressions of shame in men fairly high, too?

Ah. The answer is to tack on a different theory altogether!

Displays of shame, Tracy says, have been associated with an awareness of social norms and appeasement behaviors, which elicits trust in others. This may explain shame's surprising attractiveness to both genders, she says, given that both men and women prefer a partner they can trust.

Let's remind ourselves that women pick the picture depicting pride most often because, supposedly, that picture is all about male dominance and ability to provide for any offspring. But then the women pick a picture of depicting male shame next often, even before the neutral picture and certainly the smiling picture! Male shame is certainly not about dominance. As the manuscript I downloaded* tells us in its introduction:

In contrast to these generally positive emotions, shames' low status message may reduce attractiveness, at least in male expressers. Women who display shame might benefit from the gender-norm consistent message of low status and submissiveness, but, when sent by men, this message would be both gender-norm inconsistent and indicative of low mate value.

The results didn't support this part of the theory. Thus, a different explanation was adopted to explain this:

Women picked the high-status guys as most attractive (high-status being arms up in the air or akimbo on the hips)
Women picked the really low-status guys as the next attractive (the ones with drooping heads)

I understand that different theories can be applied to explain parts of the same set of data. But in this particular case the explanation for the two highest ranked male expressions of emotions by women contradict the underlying overall assumption that heterosexual women pick sexual partners on the basis of the men's high societal status. Despite this, the favored explanation for why the smiling expressions were ranked lowest by men returns to the social status scheme: Smiling is a sign of submissiveness and thus not something that makes men attractive to women, though of course it makes women attractive to men as men like submissive and low-status women!

It's time to point out that the draft I read does pay some attention to possible alternative societal norm explanations** by discussing how women are expected to be low-status and submissive and men high-status and dominant.

Hmm. Well, I guess that's one very concise way to add alternative explanations to the evo-psycho ones.

It also tries to avert some of the worst types of popularizations, such as the idea that men shouldn't smile at women at all or be nice. But this is not really possible, because all the popularizations in this particular class are going to be about those very ideas!

Finally, the manuscript ends with this:

In sum, although future studies are needed to test explanatory accounts for these findings, and examine how widely these results generalize (e.g., whether they hold in other cultures)...

You might have to kiss your backside goodbye on the possibility of doing untainted work on this question in the future if a sufficient number of those Internet popularizations are read by future test subjects. Just by reporting on how happy guys finish last and how bad boys are still in the fashion, the popularizations might change what will be reported and which theories people believe to be the correct ones. So it goes.
-----
*It is possible that the final article differs from the manuscript which is labeled "in press."
**Though not enough when it comes to the idea that women prefer men with resources for evolutionary reasons. The obvious reasons that a) resources have mostly been in male hands throughout the known history, and b) that the routine way for women to acquire any resources at all has been through marriage or other sexual encounters with men are ignored in the draft copy.
As a final post-script, the researchers simply removed the responses by gays and lesbians because the study subjects were shown different-sex individuals. But this seems a real waste. The responses by gays and lesbians could have told us more about the societally learned ideas of what is supposed to look sexy or not, even when the respondent had no direct sexual interest in the pictures.

A Guest Post By Anna: A Literary Canon of Women Writers, Part Two: The Common Era Before the Middle Ages

(Echidne's note: This is the second post in the series. For the first one, go here.)

Faltonia Betitia Proba (c. 306/c. 315 - c. 353/c. 366) was a Roman Christian poet, the most important and influential poet of the Late Antiquity who wrote in Latin. A member of one of the most influential aristocratic families, she composed the Cento vergilianus de laudibus Christi, a cento composed with verses by Virgil re-ordered to form an epic poem centred around the life of Jesus. Pope Gelasius I (492-496) declared the poem an apocryphal; therefore, even if it was not considered heretical, its public reading was forbidden. Yet despite this prohibition, the work had some success: it is known that Emperors Arcadius (395-408) and Theodosius II (408-451) requested copies of the poem; furthermore, during the Middle Ages this cento was used in education, and Proba's fame caused Giovanni Boccaccio to include her among a most influential women list, in his De mulieribus claris. The printed edition of the De laudibus Christi, dating back to 1472, was probably the first of a work composed by a woman. An English prose translation (since she wrote in Latin) is available in The Golden Bough, The Oaken Cross: The Virgilian Cento of Faltonia Betitia Proba, by Elizabeth A. Clark and Diane F. Hatch (Chico, California: Scholars Press., 1981).

Egeria or Aetheria (often called Sylvia) was a Gallaeci or Gallic woman who made a pilgrimage to the Holy Land about 381-384. She wrote an account of her journey in a long letter to a circle of women at home which survives in fragmentary form in a later copy. This may have been the first formal writing by a woman in Western European Culture. The manuscript has been translated several times, but perhaps the most recommended English translation for the average reader (Egeria wrote in Latin) is Egeria's Travels: Newly Translated, by John Wilkinson, especially since it includes supporting documents and notes. Another English translation of Egeria's writing for the average reader is the Gingras edition in the Ancient Christian Writers series.

The Staple Singers

It's Gonna Rain

I love The Staple Singers.

Squinting through the looking glass: Finding transparency in health care costs (by Skylanda)

How much did you pay for your last prescription? How much was your copay? How much did your insurer (should you be so lucky) cover? How much did the insurer bargain the pharmaceutical provider down before they paid their share? How much of that net difference did they tell you about? What is the difference between what would have been paid on your behalf if you had been insured and what you paid yourself if you were not? Which of these numbers do you know – are you allowed to know – and how hard would it be to find them out if you wanted to know?

Now ask the same questions about your last visit to a primary care clinic, specialist, emergency room, or hospital. If you have ever tried to scrutinize one of these itemized bills, you will already know that the layers of obscurity between you and a bottom line serve to obfuscate until you just give up and pay what they ask (or just give up altogether).

Now ask the same question about the last time you had your car repaired, or the last time you bought a refrigerator, or the last time you utilized the services of legal counsel. You may not have liked the final bill, but at least you probably know how much you were paying for which goods, parts, and services.

There are many reasons for this complexity in health-care costs. Fracturing of billing systems, multiple points of service, technological complexity, high overhead, and a number of other factors contribute to this chaos. It cannot be missed, however, that the layers of obfuscation in the health care industry both put the consumer at a distinct disadvantage and contribute the ability to incur spiraling costs - and as long as the ball is in the biller’s court, there is no incentive to change this labyrinthine structure.

For all the Rand-ian railing on health care as a free market enterprise, the health care market as it stands today defies every tenet of Adam Smith’s principles of the free market. The sellers of health care goods hold all the cards. The barriers to entry and exit from the market (for insurance products, pharmacies, and providers alike) are extraordinarily high. The ability to negotiate prices and mobilize the market in response to changing prices is impaired by the obscuring of what those prices are. The demand for certain goods is fixed because these are not goods people choose – they are goods whose need is bestowed on people by the winds of fate, and whose utilization is not optional. The only invisible hand is the one that reaches out and smacks you good and proper when you realize that the fine print of your insurance coverage specifically excludes the one condition you need it for.

Nevertheless, health care is a market, and reclaiming some of the concepts of the free market may help both with the everyday frustration of the health care system and with that elusive beast called “cost control” that everyone talks about but no one seems to be able to tame. Interesting models have arisen that give us some clues about how the world might look if health care costs were prone to a little more transparency; pry open the looking glass and take a peek.

The first model out there is the pure fee-for-service clinic. These clinics are usually small, often run with minimal to no back-office staff, and have taken the remarkable step of refusing insurance reimbursement. The charge by a deli-counter list of services and fees, and you know before you walk in how much you are going to owe before you walk out. No copays, no deductibles, no $40,000/year billing specialist to support in the back: you pay the whole bill (or submit it yourself to your own insurance), and that’s that. These have been remarkably popular options – in no small part because they tend to employ other innovative strategies like same day-only appointments, but also because of the transparency of cost: no surprises, no variation, no sifting through confusing bills, no time spent on your part puzzling over whether you’re getting a deal or getting screwed. This predictability has proven popular with both uninsured and insured patients alike.

Another more powerful – and more startling – model of transparency comes from a most unexpected place: your friendly local Walmart store. In 2006 Walmart initiated a plan to sell a couple hundred generic pharmaceutical products for $4 per month. This was not a benign gesture; it was designed to break the dominance of specialty chain providers like Walgreens and had the venomous side effect of putting a good number of mom-and-pop pharmacies on short notice also. Some of the medications cost Walmart less than $4 a month to sell, some cost more (in fact, if you read the fine print at the bottom of these lists, you will note that several of these drugs are not available in certain states at these prices; this is because these states have outlawed selling certain goods below cost as a form of unfair competition). Many people have a legitimate beef with Walmart and I won’t argue with that beef, but I will argue this: by publishing a clear list of cheap generic medications at a single price right there on their website, Walmart revolutionized the market for pharmaceuticals in America. Their list became the standard-bearer for providers caring for uninsured patients – even if there’s no Walmart in a hundred miles, the list still tells you what has gone generic, and what is most likely to be cheap at another pharmacy. The list empowered everyday Americans to be able to ask their providers if their medication was on the cheap list or not – and if they could switch to one that is. You don’t even need internet access; if you walk up to most Walmart pharmacy counters, they will hand you a paper copy of the list right there.

Several other retailers followed rapid suit, and if you don’t like Walmart, you can also find lists for Kmart, Target, the Smiths grocery chain, and some other regional chain pharmacies. Some vary slightly, so medications that you might not find at one may be available on another – but for the most part, the Walmart $4 list remains the definitive guide to low-cost drugs in America.

But, the market for drugs remains free, and just because Walmart will fork over a month’s worth of your blood pressure drugs for $4 does not mean that everyone else will too. Notorious for the highest cost among the chain pharmacies is Walgreens; I once paid $17 for a prescription that (I later found out) was on the Walmart $4 plan, and I once saw a patient pay $40 cash for a medication that was on the Walmart $4 plan. That’s up to a 10-fold difference – a full 1000%. The new twist on the pharmaceutical block is the mail-in pharmacy: some insurers “require” that you use a mail-in pharmacy, pay a set copay, and wait for your prescription to arrive in the mail; what they don’t tell you is that your total for cheap generic drugs at a chain that has a $4 plan may be less than your mail-in copay – and remember, you only have to use your insurance if you want them to pay for something. If you wanna swallow the $4 yourself, that’s your business.

At my practice (which is a pretty even split between insured, under-insured, and uninsured patients), I routinely bring up the variable cost of medications. Uninsured patients are of course interested to know that they can get medications at the most reasonable cost, and in turn I do my best to keep to the low-cost formularies whenever possible. Insured patients show some interest, especially when they have high copays or deductibles that place a larger burden on them. Interestingly, the least interested patients tend to be those on Medicaid – because at least in this state, they have no copay at all on medications; it makes no difference if their carrier pays $4 or $40, because the patients pay none at all (and while I philosophically agree with charging nothing to patients poor enough to be on Medicaid, this philosophy bangs straight into reality when I read in yesterday’s headlines that my state’s Medicaid budget take up nearly a fifth of the state’s general fund and has to cover almost a quarter of the population).

And this is why I so fervently believe that transparency of cost should apply down to the consumer level: because people are capable of making good decisions when the information to make good decisions is readily available to them – and good decision-making at the personal level can translate to cost savings at the system level. And in turn, transparency means forcing the purveyors of these goods and services to compete openly - there is no reason why one pharmacy chain can charge rapacious prices, except that consumers are kept in the dark both by a lack of an open price list and the filtering of the true cost through the insurance system.

Transparency means putting drug prices on the internet and in paper form at the point of service, and running side-by-side comparisons of costs at different pharmacies. Transparency means setting prices and sticking to them for all services that can be reasonably quantified: basic clinic visits and procedures, imaging like xrays/CT scans/MRIs, and durable medical goods. Transparency means having to compete – no more hiding behind the refusal to list prices out in the open, no more obfuscation through the filter of complex insurance algorithms, no more indulging the mistaken perception that medical costs are somehow fixed and universal. Everyone should be able to know – like they do about groceries, gas, and plumbers – who are the cheap suppliers in town and who are the pricey ones.

Overall though, transparency requires a major philosophical gear shift within the practice of medicine itself. Theoretically, cost should not impair a provider’s decision to pursue care, choose a drug, look for a cause, identify a diagnosis. I have often been told at various places that I work that I should not consider cost when I make clinical decisions; one clinic where I served was very hesitant to allow me access to a basic price list for our services because it was thought that this would bias my practice, even though patients begged to know ahead of time how much they would be on the hook for. I have called local imaging centers to try to get generate a comparative price list for patients only to be told, “Well, it depends.” (For an xray?, I want to ask, it depends on what?!).

But this world of worry-free decision making is not the world we live in – not in the free-marketeering United States, and not in any variety of the socialized medical systems either (all of which have formularies and protocols for cost control as well). We all operate in a resource-limited world, and it’s time we started acting like it: when all else is equal, choose the cheaper drug from the cheaper store; when two imaging centers are hawking high-quality MRI services, choose the one that costs less; if two primary care clinics have equally good providers at two different costs, establish yourself out of the gate at the one that costs you less.

Patients have to be able to know. Providers have to be able to know; they have also to care. And given the full power of the free market – with a transparent view through what is now a one-way looking glass – we can all start to see where costs come from and where the fat can be cut from the meat before we are instead forced to cut meat from bone.

Cross-posted from my recently relocated and re-launched blog, America, Love It or Heal It.