I see what you did there.
Ha ha! But it is worth a note, I thought. They aren’t really on private health insurance, after all.
While it/s true RAND’s cost assumptions might be off,
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It is rather unlikely the military has a significantly costlier health insurance scheme than most private insurance schemes (for like conditions - I would assume the Pentagon pays a great deal more than normal to treat traumatic injuries) and
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The numbers would be ludicrously small if they were twice as high. $17 million out of $600 billion strikes me as being a small price to pay for maintaining the dignity and honor the United States Armed Services should represent.
It is hard to compare, but the medical benefits for military personnel and their dependents are far, far more generous than anything that any civilian (other than the President) could possibly get. There are some very compelling reasons for this, of course. But a typical employee at a large company might expect to pay several hundred dollars per paycheck for their insurance plan. A dependent of a service member pays nothing, and a military retiree pays like $300 a year (or something in that neighborhood). So a typical private sector employer pays some substantial portion of health insurance costs and the rest is the responsibility of the beneficiary. In the military, the government pays very nearly all the health insurance costs, with beneficiaries paying relatively minimal amounts.
By this measure, I do think it is generally fair to conclude the the health care provided by the military is more expensive, and generally more comprehensive, than private insurance plans. (It also has some challenges that private plans don’t have to deal with, of course.)
I grew up in a military family, and yeah everything was covered. You just go to the base, and get treated. Of course, you do NOT get to pick your own doctor, and what with moving around all the time, you don’t even end up at the same hospital you are used to most of the time. But we always felt we were getting top notch care, and state of the art equipment. VA hospitals, though, I am not familiar with.
I would assume that the RAND study didn’t ignore deductibles and assumed a policy that accepted transitioning costs as proper medical procedures. Ignoring deductibles and premium copayments, given that soldiers don’t pay them, would be a very obvious flaw in their research. I would need some backing to prove they did.
I’m sure Trump doesn’t give a single fuck about the cost or the morale effect of this. It’s 100% meat to his bigot base. No other reason for this at all. Firing thousands of men and women serving their country to score what he thinks are easy political points. Fuck him.
Well, let’s not forget he has already harvested this wretched thing, he might quickly forget he even said it. I concur with the notion that he is just setting fires everywhere to distract from the looming Mueller.
I would assume that the cost of the procedures would be based on the typical negotiated costs that private insurance plans always have with providers. Like, you go to a hospital for some procedure, which the hospital bills for $20 grand, which you’re stuck with if you are paying cash. But insurance companies have negotiated that they will only pay $16 grand, and the balance is disallowed. Then the patient would typically pay some much lesser amount of that $16 grand, whatever the policy may dictate.
Basing an analysis off of the $16 grand would probably be a fairly decent way of estimating costs. The major difference being that servicemembers would likely pay a substantially smaller portion of the $16 grand than a civilian with private insurance.
I went to a VA hospital periodically for more than a decade, but haven’t been to one in 20 years. There was a reason for my stopping, and it was that they were a real shitshow then. For an appointment that normally would take an hour at most I’d have to plan to blow the entire day. The non-medical staff (administrative, clinic receptionists, etc.) were generally, but not in every case, slovenly in appearance and somewhat less than diligent about their jobs. And the medical staff weren’t what I’d call ‘up to snuff.’ I went through 5 or 6 doctors in that time, and in a couple of cases I literally had to explain my condition to them. Not my symptoms, my condition. Nor was this a backwater clinic; it was (and still is) a modern hospital in the heart of downtown L.A…well, modern is a relative term, I guess.
I can’t speak to their emergency services, never having had to use them, but I finally got sick and tired enough to get my own health insurance. Since then I’ve had two doctors, both of whom are very competent and knew exactly what I was talking about when I named my condition.
Obviously, not having been there in a couple of decades, I don’t know what improvements have been made since then. I have to hope that there were a few.
Do you really believe that will change the estimate by a substantial amount?
Enough to actually make a give-a-fuck difference?
Dammit, I missed the edit window…
I did also spend a week in Bethesda, and they seemed totally professional from my brief experience…but that was inpatient care, which I didn’t experience in L.A. either.
I don’t know anything about VA hospitals, but when we went to a dispensary on the base (that’s what we used to call them, I think), you were always dealing with uniformed personnel. No room for slovenliness there!
Yeah, I have no complaints from when I was on-base. I got good medical and dental care the few times I needed it. It was only when I was a civilian and going through the VA system that it seemed like a caricature of care.
Anyway, sorry for the derail, folkses. I got long-winded. (I do that, you know.) 
There are significant differences based on sex right up until Obama’s change. I’m not going to dig all the way down into each regulation that might have changed sex to gender after that fact. I retired right about the time of the change so I didn’t see the implementation. I know of at least one reference to separate gender, in AR 670-1 which guides wear and appearance of uniforms along with grooming standards, since the implementation of Obama’s policy. That refers to gender with the guidance being what the the Solider self reports in DEERS (Defense Enrollment Eligibility Reporting System.) I believe there was no standard beyond requesting a change but I spent my time digging through regs (or better making my staff do it and brief me 
) when I was paid to. Details of changes where sex and gender were no longer perfectly correlated due to excluding transgendered Soldiers aren’t included.
The opening of all slots to women is still in the implementation process and is getting extra attention. The Army implementation plan was a “leader first” strategy to ensure female leaders are in units before mixing sex of junior enlisted. That has made the process slower than some might expect. The first gender integrated infantry OSUT (One Station Unit Training) just graduated 18 female infantry junior enlisted, out of 32 that began the training, in May. A once over of the leader first implementation standard is here for those interested in more about what is mostly a side topic. Sex integration is still a work in progress with some differences in handling in the meantime.
Army body composition standards are sex-normed. Female Soldiers are allowed higher body fat percentage. That’s mostly a Go/No-Go (think pass/fail in normal civilian terms) standard for retention in the force. There’s some other career effects that crop up because “Presence (Military and professional bearing, Fitness, Confidence, Resilience)” is part of the Non-Commissioned Officer Evaluation Reports(NCOER). Looking chunkier, even while still meeting standard, can potentially have a negative impact on career thanks to the bearing piece.
Physical fitness testing has always been a massive difference. The new Occupational Physical Assessment Test referenced in my first link is not sex-normed. It is more of a one time Go/No-Go test during entry (with some exceptions.) The routine physical fitness test is sex-normed. The score based on that test is extremely influential. The score directly affects promotion points in the enlisted promotion system. It also shows up indirectly in other ways that affect promotion points. Fitness scores are frequently used as part of OML’s (Order of Merit Lists) for opportunities like attendance at schools that develop other technical and tactical competencies and provide promotion points. I saw reward systems that involved formal awards (worth promotion points) or things like passes to create incentives to improve physical fitness. The effects on NCOERs are both direct in the fitness category but can also pop up in other opportunities due to how it is used for so many other things. It’s a parallel to the line of argument about transgendered individuals in sports.
Uniform and grooming regulations vary based on gender in the latest version of the relevant reg. A lot of that is superficial stuff like different dress uniforms or being allowed to wear a modest amount of cosmetics. There are also things like protecting cultural senses of modesty that can have some overlap with sexual harassment cases. I could lawfully order male Soldiers to strip down to their t-shirt on a work detail. I could authorize that uniform modification for female Soldiers. I don’t recall off hand if that limit was a regulatory protection or one implemented by typical local policy and/or standard operating procedure. Either way I felt quite effectively constrained to treat the sexes differently. No orders that could be construed as a female Soldier participating in an involuntary sweaty t-shirt contest left my lips.
Urinalysis. The Army doesn’t send you out to a clinic for drug testing like most civilian employers that have the requirement. We do it internally and someone has to watch you fill the bottle to prevent possible cheating. Colloquially the male observers were often referred to as “meat gazers” during my time, if that gives a sense of the invasiveness. It’s the bathroom privacy controversy taken to the extreme. Privacy concerns were addressed by matching observer sex to the sex of the sex of the person being observed during my service.
Housing, showers, and bathrooms (sometimes without stall dividers) all were sex segregated. To some extent it’s more of the extreme bathroom/changing room debate again but it also includes housing and sleeping arrangements. I’ve had conversations with “coworkers” while we were both sitting on a toilet next to each other…while able to make eye contact. Quarters are assigned for those that are not in family housing. It’s not a pick your roommate situation. Sleeping in austere conditions doesn’t have normal civilian workplace norms; you literally sleep with coworkers at times. I’ve been snuggled, groped, and been the target of the leg hook while sleeping. I (A little non-gropey spooning was kind of nice when it was cold. ) Civilian cultural expectations of body privacy and personal space go out the window in tactical situations and austere environments. Where possible the Army made significant efforts to manage the intrusiveness of that by sex segregating.
Some of the differences are, as I noted, just dealing with a much more extreme version of the bathroom/changing room arguments about privacy. Some are relatively superficial uniform and grooming issues. Some have real career implications based on different birth physiology changing physical performance.
The root cause of the problem is he doesn’t believe we have an actual medical condition that needs treatment. Like many, he appears to think it’s an optional expense, like going to college, or else he wouldn’t have proposed rationing out benefits.
An interesting article on why President Harry Hairshirt probably can’t get away with removing already-serving trans people:
http://www.cnn.com/2017/07/27/opinions/trans-military-ban-opinion-minter/index.html
My sense is that he can still stop the gender reassignment surgeries, and the ban is sure to affect recruitment, but no joy on removal.
And since plenty of folks specifically join the military for the college benefits - with full plans to leave after the minimal time is up to get them - and others join a longer term to get even more specific college education beneifits (Drs, nursess, what have you) - then I see absolutlely no reason that a person that might join for medical benefits (I know that when I joined years and years ago, med benefits for spouses was a good reason) to be a ‘problem’ either.
As I believe you’ve stated before - not all transgendered individuals need more than routine medical treatment - they are not ‘diseased’ or ‘handicapped’ in any way by their condition (beyond what ‘social norms’ are imposed upon them that cause stressors, etc).
To try to head off the concern over the RAND numbers, let’s set an absolute upper limit here.
FWIW here’s my back of the envelope calculations.
Assumed: 2,500 transgender persons
Assumed: 2/3 are transwomen, 1/3 are transmen
Assumed: NONE have had surgery of any sort prior to enlistment (this is a really conservative assumption; several who I know had at least some surgery prior, but let’s look at the worst-case)
Assumed: SRS and breast surgery are covered. Facial cosmetics are NOT. Nor is hair removal (something never considered to be covered by insurance anyways)
Assumed: Each soldier stays in 4 years on average (some may be at the end of their tour)
Assumed: cost of female hormones plus antiandrogens are $40/month (estradiol, finasteride, and spironolactone, from Wal-Mart w/o insurance).
Assumed: cost of male hormones $75/month w/o insurance (various personal accounts; I don’t know if Wal-Mart sells them at that price).
Assumed: transfemale SRS+breast surgery $25,000 (this is on the high-end of US costs, like Bowers et al. In Thailand the costs would be about $10,000-$15,000).
Assumed: transmale SRS+breast surgery $75,000 (varies greatly, can be from $40k-$100k)
Assumed: based on recent figures we use at our clinic, 75% of transgender women will have SRS in 5 years, and 40% of transgender men (due to the much lower success rate of transmale SRS). In reality, many transmen will simply have breast removal and a hysterectomy, which is about $12,000 total. The true fraction who have complete phalloplasty is likely closer to 0.2 over 4 years, but let’s just stick with high-end numbers.
Assumed: everyone who wants to have surgery has it within a 4-year window. Seems unlikely, but let’s go with it.
Transwoman hormone cost over 4 years: 1,667 persons * 12 months * $40 * 4 years = $3,200,000 (this ignores those who have surgery early, and thus can cut hormone costs down to about $5/month for 2 mg E per day)
Transman hormone cost over 4 years: 833 persons * 12 months * $75 * 4 years = $2,998,800 (no benefit from SRS here, although some transmen do stop T after surgery)
Transwoman surgery cost: 1,667 persons * 0.75 * $25,000 = $31,256,250
Transmale surgery cost: 833 persons * 0.4 * $75,000 - $24,990,000
Total cost, 4 years: $3,200,000 + $2,998,800 + $31,256,250 + $24,990,000 = $62,445,690
Cost/year over 4 years: $15,611,423
There’s a very high-end number. If it’s off by a factor of 2.0, then it hits the upper limit of RAND. I’ve made so many broad assumptions on the side of high-cost, I cannot help but see that I could be 2.0 times higher than reality.
But even at the worst case, it’s about the same as 8 Trumpian golf outings. And the conservative outrage can be found…where, exactly?
I agree, everyone in uniform should have the same chances at the same package of benefits. One of those benefits should be medical care for any conditions they might have. Those medical conditions should include treatment for gender dysphoria, to whatever extent is deemed necessary by a qualified medical professional. Your other benefits should not be reduced because you suffer an illness or injury. A soldier who gets shot, and requires $100,000 of medical treatment, should not have his college benefits cut by $100,000 to compensate. Neither should a soldier who develops cancer. Neither should a soldier suffering from PTSD. And neither should a soldier who is diagnosed with gender identity issues. The treatment for all of those medical conditions should be open to anyone who serves - and no soldier should be punished because they’re happen to fall into one of those categories, when another soldier who’s lucky enough to make it through his term without getting sick or injured gets rewarded with more benefits.
How have you lived through the last eight years of constant debate over health care in this country, and still have such a fundamentally ignorant idea about how health insurance works? Jesus, why would anyone buy health insurance if it worked the way you just described? That’s literally just a bank account!