A couple of weeks ago, I talked to a random guy at a bar who dropped this gem on me: Name a country that has women’s rights that isn’t run by white people. I was a little flabbergasted, to say the least, that someone who make such an openly racist claim. My first reaction was to ask if he could name a country that had a lot of rainfall but didn’t have trees. Because that felt like the same back-assward way of looking at things.
But the statement ate at me. Why, exactly was this wrong? Was it even true? I know that the US doesn’t have the greatest record on women’s rights – smaller political representation, among the very few countries with absolutely no maternity leave. But even if this statement is literally true, why is it a misguided way of looking at the world?
The first stop is the World Economic Fourm’s Gender Gap report for 2015. This report addresses the gap between men and women’s outcomes in various countries. That means if a developing country has deficiencies in some area – say education or economic opportunity – they only consider the difference between how men and women are treated. If everybody enrolls in the same terrible schools at the same rate, there is no gap. The list ends up being pretty heavily weighted by economic opportunity and political representation, the categories with the biggest variation.
The top three, according to their metrics, are all Scandinavian: Iceland, Norway, and Finland. The bottom three are all Muslim: Pakistan, Syria, and Yemen. Bar guy would have liked this. In fact, 17 of the top 25 are majority white countries. But here’s the thing: these countries all spend a good portion of their GDP on social services. These countries are generally wealthier and spend a lot more of that money through their government. As this chart breaks down, being in a wealthy country that spends money on its people is a better indicator:
Having women in politics doesn’t hurt either. I included the USA in there because that was my racist friend’s baseline. As a wealthy country that doesn’t spend a lot through the government, women do okay, but not among the best. And we have terrible political representation.
There’s a couple of non-white countries in the top ten: Rwanda and the Philippines. Neither of these countries is wealthy and neither spends a lot on government. But both have better female political representation and economic opportunity. And both of these countries have about doubled their GDP since 2006.
But this may not have been what he meant. The World Health Organization released a report on violence against women throughout the world. Overall, 1 in 3 women will be victims of violence, either by an intimate partner or sexual violence by a stranger. This graphic breaks it down by region:
Violence against women is generally higher in the Global South, but again, the key indicator is wealth. Places with lower incomes have higher rates of violence against women. If you look at the Western Pacific Region – majority non-white – they have slightly lower rates than Europe. They also have generally higher income than their neighbors to the southeast.
So if women have more rights where incomes are higher, and the places that have higher incomes are generally full of white people, doesn’t that mean that racist guy is still right? Well, no. In fact, it’s not even wrong. His statement has a big ass logical fallacy in it that implies that white people are somehow better as a group because they have the financial security to treat women with some equality. These countries have a sort of Maslow’s hierarchy thing going on: they’ve got a pretty good handle on the biological and safety needs and will help out those who struggle, so that their citizens can think about the top-level items, esteem and self-actualization. Poor countries struggle to feed their people and suffer from preventable diseases like dysentery, developing countries are trying to build out industries, power grids, and transportation infrastructure while battling worker exploitation and pollution, while the rich countries get to think about individual rights and global status.
Hell, the entire idea of civil rights is relatively new. Less than two hundred years ago, you could own people in the US and other supposed enlightened white countries. Three hundred years ago, the major European powers thought nothing of invading places on other continents, claiming dominion, and butchering the populace if they resisted. The US is proof of that. The fact that it is now majority white means that the darker skinned native population that existed beforehand was largely wiped out.
Women’s rights is something we’ve only been working on for about a hundred years. And the European countries didn’t have to deal with freeing themselves from a foreign yoke. Now that they have the ability to make their own decisions (though this is debatable with the demands that any World Bank money come with), give them some time to come around. It took the US about a hundred and fifty years since we kicked our British masters out (not to mention that the people who kicked them out were also basically British). Most of the countries that have less women’s rights have had independence for fifty to one hundred, at best.
When I quit my job last May, I also quit my health insurance plan. Not on purpose, really. Like every other health plan I’ve been on during my adult life, it was provided and mostly paid for through my employer. But now that I am footloose and fancy freelance, I’ve got to pay for my own insurance. So I got one through the Affordable Care Act (ACA) exchanges.
I paid a little extra to get a plan that had both my primary care physician and the ENT who has been making my sinuses slightly less terrible. But when I got my insurance card, I had a different physician listed. At the ENT office, they seemed surprised that they were even listed there. “We’re not in any of the ACA networks,” they said. “We’re already in so many networks that it’s not worth it.”
I liked those doctors a lot. But none of them are in any ACA networks. And they aren’t the only ones. According to a study by Avalere Health, plans offered through the ACA exchanges have 34% less providers than the average employer-based or individual non-exchange plan. So you may be able to keep your doctor if you like them, you just have to pay full price for services.
According a report by the Robert Wood Johnson Foundation, 40% of ACA plans are considered small or extra small – that means that less than 25% of available providers are within their networks. I’m lucky; I live in New York City, so I can find another primary care provider nearby. But can you imagine the huge hassle it must be if you live in a small town? 25% of doctors could be one.
Insurance companies are narrowing networks in order to lower the rates they charge. They get pickier about the doctors they use – they want a high quality to efficiency ratio. On the face of it, that seems pretty good, right? You get solid, waste-free doctors, sawbones who get the job done without cost overruns.
But this isn’t exactly right. When the insurance companies narrow their networks to lower costs, it’s not just because they are being choosy. The costs go down because they reimburse less for procedures. Doctors will join these narrow networks because the limited number of available doctors means that more patients will be sent to each individual practice. Narrow networks create volume-based health care providers.
So why are some doctors not on any ACA networks at all?
“The exchanges have become very much like Medicaid,” says Andrew Kleinman, president of the Medical Society of the State of New York . “Physicians who are in solo practices have to be careful to not take too many patients reimbursed at lower rates or they’re not going to be in business very long.”
The short answer is that doctors who take a lot of ACA patients like me will go broke. Now that we get to see the actual costs of insurance instead of having secretly tacked on to the end of our pay as a benefit, we want cheaper plans. But that means lower reimbursements to doctors (the whole reimbursement dance is clusterfuck for another post), which means less doctors sign up. Klienman says the reimbursement rates can be less than 50% of what the commercial plans pay. Plus there the huge deductible you have to burn through before insurance kicks in a pays anything.
On top of that, I have a 90-day grace period for my insurance payments, but the insurer won’t pay reimbursements unless my account is paid up. Doctors on the network have to take me, but won’t get paid until I remember to write that check.
We’re creating a two-tiered system for insurance. People like people who don’t get insurance through their job have less access to providers. On top of that, we get access to doctors who are willing to take lower rates for more patients – either doctors without enough patients, those willing to run a volume business, or new doctors. Single payer, where for art thou?
I still thought I was getting what I wanted. But no, the directory was wrong. And that’s a growing problem. Brian Hoyt, managing director at Berkeley Research Group, wrote in a recent white paper that “Provider directory inaccuracies represent a growing and significant risk both to consumers and health plans. Inaccurate directory information may limit a consumer’s ability to verify if a preferred doctor is in-network, or to know how many and what types of providers would have to be accessed under a particular product offering.”
These inaccuracies have led to lawsuits against the insurance providers. Which is going to raise my health insurance premiums.
I know this is the beginning of a new system. Under the old system, I would have gone for the cheapest plan possible, which was no insurance at all. This way, at least I’m covered if I get hit by a car and they find a brain tumor. But I’m less likely to consider getting that checkup to catch the tumor early.