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November 19, 2009

A Botox tax is kind of sexist

Like Jill, I've got misgivings about the provision in the senate healthcare bill that would defray the costs of reform by levying a 5% tax on cosmetic surgery.

In practice, a plastic surgery tax would be relatively economically progressive. Plastic surgery is, after all, a luxury. But if this is really about progressive taxation, why not just tax the rich? Why single out relatively rich people who get their eyes done, rather than buying Hummers, or other luxuries?

According to one estimate, 91% of cosmetic surgery patients are women. (The American Society of Plastic Surgeons says 86%.) Yet, it's not as if women who get cosmetic surgery get 100% of the benefits, nor do they supply 100% of the pressure on other women to get these procedures.

It’s one of those classic sexist double binds: Society tells you that you have to look perfect and then sticks you with a ’sin’ tax when you do what’s expected of you. If you tax cosmetic surgery, boob jobs will titillate men and subsidize their health care. Cui bono?

The standard argument for a health-related sin tax is that the extra cost will deter people from engaging in the unhealthy behavior, and/or help pay for the public health consequences of overindulgence. Cigarette taxes are a prime example.

If the cosmetic surgery industry withered and died, it would probably be a boon to women and aesthetics in general.* But a 5% cosmetic surgery tax probably won't deter anyone from getting work done. If you can afford a nose job in the first place, an extra 5% isn't going to stand in your way. And unlike soda pop or cigarettes, privately-paid cosmetic surgery isn't a significant driver of health costs nationwide.

Unless you see this tax as a tool for reducing cosmetic surgery rates; and reducing cosmetic surgery rates as a tool to enhance public health--why create a special tax on these procedures? If it's just about raising money, you could slap a surtax on anything Gasoline hurts our health way more than someone else's boob job. Ditto high fructose corn syrup. If you really wanted to reduce cosmetic surgery rates, why not tax the adult entertainment industry or fashion magazines, for creating a market?

Taxing cosmetic surgery seems like, effectively, a form of slut shaming. It's an excuse to punish women for being vain or frivolous or sexually provocative. Once again, society puts massive pressure on women to look good and then throws gendered insults back at them when they take that directive seriously.

*Not that there's anything intrinsically wrong with cosmetic surgery. In an ideal world, it would be just one more option that people could freely choose. In the actual world, sometimes it seems like more of a burden than a benefit. A lot of women feel pressured to get work done just because it's possible and other people do it, not because the actual results of the procedure are so great.


One of the reasons for sin taxes is to discourage activities for which there is unhealthy social pressure. It's no different from smoking or drinking - the people who supply the social pressure on young people to drink and smoke are often not the people who then pay the taxes.

Young people might have to consume fewer cigarettes if the price goes up by five percent because they don't usually have that much money to being with. I don't think that most cosmetic surgery consumers are going to be put off by a five percent tax.

I don't think there's any product where most consumption is put off by a 5% tax. In all cases, only a small part of consumption is. That's why for genuine public health crises, like smoking, the tax isn't 5%, but more like 200%.

Maybe its proponents have argued for it as a "sin tax," but my first thought was that it's more of a rich tax.

It strikes me as a political stunt, because it's a hard tax to oppose in the political arena. Like a "yacht tax," or a luxury car tax, if some Republican criticizes the tax, the liberal talking heads will be able to pounce on him for wanting to cut taxes for rich people.

The part that's really going to cause trouble is the exception for congenital abnormalities. Want to bet that lobbyists for the cosmetic surgery business have a really broad definition of "abnormality"? Micromastia for everyone!

I wonder if the doctors/hospitals will be sending the federal government the names of the patients who get cosmetic surgery when forwarding the tax payments.

There is a privacy issue in how this is implemented.

As I wrote in a comment on the Feministe thread, in point of fact it's not clear that it's progressive. 71% seeking plastic surgery make less than $60,000/year; 30% with an income of $30K or less; 41% with an income from $30K to $60k. (Assuming this article is reliable.) It's not a luxury tax, in the ordinary connotation of the term, unless we count sin taxes as luxury taxes. Yes, elective cosmetic surgery is, by definition, non-essential (as it's elective). Now, there's a wide range of procedures some costing hundreds of dollars (Botox) and some costing thousands (most surgeries). (Botox and similar procedures are repeated more often, as well, I believe.)

I don't see how this is more progressive (or more of a luxury tax) than an alcohol tax, even if rich people spend more on alcohol (because they buy $2000 bottles of wine, a lot. A special tax on $2000 (or perhaps $20,000) bottles of wine seems much more like a standard luxury tax. If you tax goods that are not affordable to lower income people, that's probably progressive. But if you tax goods that are relatively expensive but still affordable (though perhaps via nasty financing) and highly desired, then your tax is unlikely to be progressive. It may be, nevertheless, reasonable (as, perhaps, sin taxes are), because a key aspect of the tax is discouraging the behavior. But that's a very different argument.

Sounds non-progressive (given analysis above) but I think this is an "arms race" issue. If a woman gets a competitive advantage (in whatever competition matters to them) from cosmetic surgery, then she has an incentive to get the surgery. If it were unavailable or grossly expensive (which 5% is not), everyone would make do with what they had; outcomes would change only a little, plastic surgeons would be poorer, and those that admired the outcomes (mostly men) would adjust their expectations.

Is it only for elective cosmetic surgery or would it hit kids with cleft palates or burn victims?

I haven't read the bill, but I've heard that reconstructive cosmetic surgery is exempt. It should be. Also, legislators should make sure they don't end up taxing procedures associated with sex reassignments. Transfolk have enough burdens as it is.

I'd guess it would mostly be a tax on rich guys paying for elective surgery for their trophy wives.

But anyway I'm all for replacing sin taxes - which are regressive - with taxes on the rich. Sin taxes are all about busybody rich liberals telling poor people how to spend their money. Education is the way to change people's behavior, not this patronizing behavior-modification-through-taxes-method.

The botox tax seems trivial compared to this: About the new guidelines for breast cancer screening, the American Cancer Society, the American College of Radiology (ACR), and the American College of Obstetricians and Gynecologists (ACOG), among others, find the new recommendations “objectionable.”

It turns out that this study was originally commissioned under the Bush administration, and there were NO, I repeat, NO oncologists serving on that panel. What a fraud! Another old story to recall: remember the time when the Bush administration tried to appoint a veterinarian to the Office of Women's Health?

When I return later, I intend to re-write this into a dedicated post. For now, let me just say this: If the GOP tries to spin the mammogram story into more "death panel" propaganda, just throw this crap back at them.

"There is a privacy issue in how this is implemented."

I don't really see why. I mean, on the one hand, the doctors are already paying income tax on the money they earn for doing the procedures, so they already have to have information on the number of procedures they do at least for accounting purposes, and whereas the consumption tax angle comes in, it's not like it wouldn't work like sales tax does now. Wal-Mart doesn't forward the government a list of everything you bought from them so they can send you your sales tax bill, they add the charge on at the time of payment and then forward it to the government.

If they were to put a heavier tax on this, one easy way to avoid it would be to have it done in a qualified practice in another country. Where the surgery would be cheaper in the first place.

The Dems can give a nice " stimulus " to the medical tourism industry.

Or we could always reduce the size of government and not pay those taxes at all.

Just saying.

Fustian, you're right. I vote for slashing the budget of the F-35s, which are useless in just about every conflict the US is likely to get itself embroiled in.

But, as we all know, a huge military budget isn't big government.

And Peter, if you could come up with a way of cutting smoking rates without cigarette taxes, you'd be able to publish in any scientific journal you'd want, and your future career in public health would be guaranteed.

Peter K., "I'd guess it would mostly be a tax on rich guys paying for elective surgery for their trophy wives."

I don't think that's a good guess. See my earlier comment.

(I was tempted by that guess, too. My initial analysis of its sexism didn't rely on non-progressivity, but just the disproportionate affect. I still think that, most likely (with lots of possible exceptions), it's less horribly sexist than the anti-abortion rider, at least in overall effect. However, if what makes it acceptable, or non-sexist, is its progressivity, I think there's a pretty strong burden to show that it is, in fact, progressive. With the fact that 71% of procedure seeker households make under $60k/year, I think that's pretty unlikely.)

Bijan, just because a social ill is consumed primarily by women doesn't make a sin tax on it sexist. Not even the most obnoxious men's rights activists call cigarette taxes anti-male, even though at least in the heyday of smoking, men smoked at far higher rates than women.

And, yes, I think Botox and other plastic surgeries promote social ills. First, they ration health care in a suboptimal way - they raise the overall demand for surgery, which raises prices for procedures people actually need, such as reconstructive surgery. So in that sense, you can think of a Botox tax as a kind of congestion pricing, except that it doesn't actually tax medically necessary procedures, only elective ones. And second, you could argue that the social effects of plastic surgery are bad because it encourages women to objectify themselves - for example, the social pressure on Asians to have eyelid surgery would become slightly weaker if eyelid surgery cost more.

It's not sexist just because most of the people who get the surgery are women. It's sexist because it dings the patients and ignores all the people who "consume" the end products of plastic surgery and pressure women to get it in the first place. If men buy most of the cigarettes, they get all the benefits of smoking (such as they are). One of the reasons feminists regard plastic surgery with scorn is because women get the pain and men get the benefits (such as they are).

I'm not saying that 100% of the beneficiaries are men, my point is that there's a larger cultural pathology at play and it's not fair to single out the class of people who are already bearing the brunt.

If we need money to pay for health care, tax everyone who can afford it, not just people who make choices we regard as suspect--unless there's some compelling public health case to be made for a targeted tax.

Alon, I don't think that just because a "social ill" is consumed primarily by women makes a sin tax on it sexist. I don't see where I argued that.

But I don't think that just because something is a social ill that all taxes on it are sin taxes nor do I think that merely because they are a "social ill" that it would be non-sexist to sin tax them. That seems as much of a non sequitur as the argument you imply I made. Easy counterexample: If only social ills primarily performed by women (the ills of which primarily affected those women) were sin taxed while social ills primarily performed by men (but whose negative affects primarily affected women) were not sin taxed, then I think the sin taxes are probably sexist. Thus far you merely (and, may I add, rather weakly) argue for reconstructive surgery being a social ill. I'd like to think that too. I certainly think that the pressure women experience to "perfect" their appearance is a social ill. But I don't see how making surgeries (or cosmetics, or whatever) somewhat more expensive alleviates that social ill. Rather, as Lindsey has pointed it, it makes it worse (or can). Why do you think the social pressure on Asians to have eyelid surgery would be at all weakened if it became 5% more expensive? It seems as possible that the pressure would go up, either because it was more expensive, or because the pressure was independent of the price (within certain bounds). Or the pressure could stay the same, but some women feel squeezed between the pressure and the increased price.

In any case, I don't think that just because something is a tax on a social ill makes it a "sin tax". Sin taxes are taxes designed to reduce or effectively discourage a societal ill. To be effective at that goal, then typically need to be part of a broader policy effort (e.g., the multifaceted anti-smoking efforts). This doesn't pass any of the prima facie tests (it's too low; it was passed strictly to raise revenue; and there is no other policy effort or even rhetoric for the goal).

(I suppose you could have a weaker notion of sin tax wherein you don't hugely care if the activity is discouraged by the tax because either it isn't, and you get lots of revenue, or it is, and you reduce a harm. But then the analysis of whether its sexist has to acknowledge the first case.)

Your first argument needs empirical backup. I think it has to presume a strong inelasticity of supply (including of plastic surgeons), no economies of scale, no effects of increased competition, etc. for there to be price increases on "necessary" surgery. It seems to me that the explosion of interest in plastic surgery hasn't made it more expensive, but rather less so. (From my cursory examination of the stats.) So, I would like at least some evidence for your claim.

I rather suspect that cosmetic surgery is an easy target because it is primarily pursued by women and it is conceptualized as a canonical example of vanity (and thus frivolous). Yes, the predominantly male plastic surgeons will oppose it, but I doubt they are as effective lobbyists as rich people in general. Plus, there's a nice narrative that co-opts both sexists ("It's that silly, pointless elective stuff that silly frivolous women abortions. So it's ok to tax that") and anti-sexists ("The cosmetic surgery industry exploits sexist societal pressures on women! Maybe this will help. And it's progressive so only people who can easily afford it pay.") Even if it happened to have a beneficent effect for women (either directly, by reducing the social ill on them, or indirectly, by funding their insurance), it could be sexist (albeit, not the worst you could imagine). After all, the indirect case might apply to the Stupak amendment. It could happen that the elimination of insured abortions was globally offset by the benefit to women of reformed health care. (That is, by some global metric, the welfare of women was net increased, though that of women with unwanted pregnancy went down.) But that doesn't make it non-sexist! It's egregiously sexist.

Even if a sin tax on plastic surgery would be justifiable on it's own terms, I find it pretty suspicious that a bill that deliberately neglects some inherently female health needs gets partial funded by a tax that disproportionately hits women. It's even more suspicious that both provision hit poor women much harder. So, yeah, still going with that its sexist.

The bill doesn't inherently neglect female health needs. It inherently neglects abortions, while inherently making it harder for insurers to consider being an abused wife a preexisting condition and charging abused wives higher premiums.

The Stupak amendment doesn't increase services to women by itself, so it's different. But yes, some pro-choice Democrats voted for it on the belief that it was necessary to make the full bill pass, and therefore was a necessary evil.

The explosion of interest in plastic surgery hasn't made it less expensive - it's made it easier to finance via debt. And meanwhile, every doctor who chooses to be a plastic surgeon is a doctor who isn't going to do something useful. The supply of doctors in the US is fixed: the AMA fixes quotas for med school applications and makes it impossible to recognize foreign doctors' credentials. Due to AMA regulations, there is a strong inelasticity of supply of doctors, if not of plastic surgeons specifically. If there is any economies of scale, or a competition effect, I'd like to see it. In general, the private care system in the US does not create any competition, and does not do things more cheaply than government monopolies like the British NHS.

There are reasons to just tax plastic surgery, rather than also do awareness campaigns as with smoking. First, you don't want to conflict with anti-obesity campaigns; obesity is a much bigger public health issue than competition for scarce physicians. Second, awareness campaigns of the "Don't undergo elective procedures" type not only are a political nonstarter, but also could create additional complications as people choose to forgo preventive medical service that they don't think is necessary.

Alon, I think you are reading my implicit quantifiers funny. "Inherent neglect female health needs" isn't charitably read as "inhernetly neglects *all* female health needs." But your example sort of make the point: Correct me if I'm wrong but the reason that the abused wife as preexisting condition horror is alleviated is because the nastiness of all prexisting conditions is alleviated. (This is good, and a benefit, no doubt.)

The bill does not fund a health issue for women, abortion, and has the likely effect of eliminating insurance coverage for that health issue:

The study finds that “the treatment exclusions required under the Stupak/Pitts Amendment will have an industry-wide effect, eliminating coverage of medically indicated abortions over time for all women, not only those whose coverage is derived through a health insurance exchange”

This doesn't make the bill the worst bill evah. It means that it has a seriously sexist provision at the moment. I've said nothing about the motivations of anyone who voted for the bill, nor whether voting for the bill with this provision (or the tax on plastic surgery) isn't the on all considerations right, if unfortunately, thing to do. The questions is whether the Stupak amendment is sexist. I hope you agree it clearly is. Now, is the tax on plastic surgery as a funding mechanism sexist? I think it is. Partly because of context (the bill denies coverage, on the one hand, for a basic and common procedure that affect only women and, on the other hand, taxes elective procedures that happen to be chosen predominantly by women; in both cases, poor women are disproportionately affected). Do you think it's an accident that plastic surgery was chosen? Do you think that people were motivated by the need to improve the situation of women? (Yes, now I'm appealing to motivation, but I think it's more of a component here.)

Re: number of doctors. You've moved from inelasticity of plastic surgeons to of doctors overall. This article paints a slightly more complicated picture (i.e., that there isn't necessarily an overall shortage now). It's not clear that people will be attracted to the needed specialities if we contract the number of plastic surgeons.

I'm still waiting (and looking!) for numbers. Ok, here's some for Botox, which I expected to fall in price, not outstrip inflation. Hmm. Surgery is hard to estimate since there are (roughly) procedure independent costs (e.g., anesthetics) and potential competitive effects (if there are 100 plastic surgeons rather than 50, we might expect their average feed to go down). Sorry, the Botox numbers are the only ones I could find. So I can't adjudicate between your increases costs and others lowers costs (overall).

However, your original point was that it raises costs for non-elective procedures. Now that should be covered by insurance, so not hugely affect the out of pocket effect (pace, sane insurance, which presumably the bill brings, at least to some degree). The many points about how trans people will be affected come to mind (that is, unless sex reassignment is covered, the tax will hit trans folks harder).

I completely don't buy your last paragraph. First, it's not clear how cost sensitive plastic surgery consumers are. For example, this survey claims that only 20% of those who hadn't purchased implants didn't purchase because of cost. (It's unclear whether that meant they were saving for it.) (That survey is very interesting overall, if reliable. Comparative few surveyed claimed to made the decision based on partner pressure; many reported negative feedback from their partner; over 70% thought that the media put too much pressure on women and that men's standards were too high). So, the real effect is likely to be wealth transfer. That is, an unprogressive tax.

Second, why would you think that the substance of the campaign would be akin to a smoking one? A public health campaign designed to reduce the incidence of elective plastic surgery could focus on bolstering women's self-esteem, reducing negative media portrayals of "unattractive" women, etc. So how does this conflict? How isn't that needed? (Consider anti-size zero campaigns.)

Third, given that this tax is likely ineffective at furthering your policy goal (at least, because of cost insensitivity at this level, and possibly because there isn't interesting fungibility of plastic surgery; that is, it's not clear that reducing the amount of elective surgery (that such measures would produce) will have a significant freeing of other resources), and is likely to disproportionately affect poorer women, er...why is it non sexist?

I'm open that it isn't sexist, I get, but there is way more than a prima facie case there. I worry as well that it is a soft target so it's easy to say, "Well, plastic surgery is trivial anyway, and it's all rich trophy wives, so it's all good. Besides, a tax will discourage it and thus raise women's self esteem. Or at least let them get less surgery." (I wish these were the case. But I don't see that that's plausible. And it's definitely not a good default.)

And it's convenient that it's a woman dominated one that happens to get the hit. Out of all the funding mechanism we could select, this one is the best? Or even in the top half? One that happens to disproportionately hit women? And poor women?

I can imagine a policy that included such a tax that was substantively nonsexist. Maybe. This doesn't seem to be it.

Eek. Did I really use up all that comment space? Sorry! Alon, if you want to continue (perhaps have a last post) we can take it off line.

Bijan, no need to take this off line. It's a fascinating discussion. Use as much space as you need.

I took a friend to a plastic surgery clinic so she could get some scars from a burn patched up. The surgery and recovery took a few hours during which time I sat in the waiting room. Many people came through the waiting room, a large proportion of whom were thirty- and forty- something year old women who had no apparent scars or disfigurements whatsoever. I kept searching their faces to see what was wrong, expecting to find keloids, or broken noses, or something and it took me an hour or so (ok, so I'm not Sherlock Holmes) to figure out that they were there for boob jobs. It was decidedly saddening to see women who had nothing at all wrong with them volunteer for the pain and expense of totally unnecessary surgery. The women seemed like the type who don't leave the house without makeup and have shower stalls full of hair care products. I found myself wishing I could tell them that they looked fine enough not to waste a minute worrying about what they looked like. I don't think taxing them is the way to do that.

The rich in this country get away with pulling far less than their fair share of the weight and they should be taxed for being the parasites that they are, but putting the burden on women who've been sold a twisted notion of beauty won't help.

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