I can always work my way through an issue intellectually in a fashion that dissipates or checks my quick, easily manipulable gut feelings about the political news.
Take the Citizens United decision. My quick emotional reaction was, “Well, that’s it, then, that puts a stamp of approval on the inexorable decline of the United States and its experiment in democracy.”
The push-back from my brain:
1) Come on, what past era of American democracy are you thinking of? The entire second half of the 19th Century, when national, state and local politics wallowed in flamboyant corruption that would make the worst corporate whore today green with envy? Huey P. Long? Lyndon Johnson, when he was in Congress? Nixon?
2) Come on, didn’t the Supremes merely confirm what we already know, which is that all existing efforts at statutory restraint of corporate and special-interest influence have failed utterly, that most U.S. politicians are already in some pocket or another, that the whole system long since drowned in a riot of competitive interests buying favors?
3) Sometimes the interests of particular groups or institutions serves a larger public, if often by accident. Important and useful past public initiatives have been backed by groups and businesses who stood to make a buck. Nothing worthy happens because of a high-minded altruism that’s above any self-interest.
But somehow my heart isn’t responding to that push-back this time. Some people have gotten very angry. I’m more in the class of people who feel completely despondent about the political and social events of the last few months. It just feels to me as if there are many things which could happen which would improve the lives of many Americans which are not going to happen and perhaps cannot happen.
Take health care, for example. I can read and parse and think about the proposed legislation that actually exists and see it without hyperbole, as an okay if scattered series of modest initiatives. Whatever. I think I have a fairly good handle on the underlying cultural and social infrastructure of the debate over health care. Like many of the “controversies” of our moment, it is both less and more than it appears, and in either case, pretty well intractable and hopeless for anyone who isn’t jumping into the fray as an enthusiastic combatant. Also whatever. I can Monday-morning quarterback as well as any other chattering-class person and complain about the uninspired tactical blundering of Democratic leaders and the obstructionism, untainted by consistent principled objections, of Republicans. But again: whatever.
When I think of my own health care and slip the leash of my intellectualizing, some different thoughts come to mind. I have a decent HMO plan. I’m guaranteed to have it while I have my job, at least until or unless I’m not guaranteed to have it because the provider unilaterally renegotiates the terms of its deal with workplaces that it sells plans to. My job is as secure as you could hope for in early 21st Century America. I’m not rich, I’m comfortable. If I need medicine or surgery, I’m not likely to go broke. If I develop a pre-existing condition, my continued coverage is guaranteed by my employer.
On the other hand, remember those commercials back during the Clinton Administration, “Harry and Louise”? Remember all the horrible things they said would happen if we changed our system? They mostly did happen. Here I’m not talking the grand scale, I’m talking my own intimate experience of health care.
When I first started working at Swarthmore, I had a PPO plan called Personal Choice. It was a great health care plan. I had to stay inside the network for non-emergency services, but I could make appointments myself, no referrals necessary. It paid for preventive medicine as well as other medical services. Doctors were compensated at a slightly higher rate for PPO patients and so I felt that when I did show up, I was treated with some degree of respect.
That plan got priced out of reach because the people who had it tended to actually get medical treatment more than people with the HMO tier. Which made it clear that the HMO tier is designed to discourage usage of medical services. Which for me at least it does. Now when I see my regular doctor, I get a very strong feeling that I’m on the clock. She has ten minutes, no more, for me. I get a very strong feeling that the pressures on her and the overall network also lead her to push me towards tests and drugs, partly to get me out of her office and partly to bump up fees or build relationships with pharmaceutical companies. I don’t feel I can make the same choices about specialists, and the referral procedure feels like a barrier. I get a sense that people who know nothing about me, and perhaps nothing about medicine, are making the choices that really count behind the scenes about my own treatments, and about the entirety of the services to which I have access.
Like a lot of middle-aged men, my own health is a subject about which I feel unreasonably fragile. My heels hurt from what I assume is tendonitis. I don’t know that there’s any point in seeing anyone about that, so I haven’t. I have an odd sporadic pain on my left side that when I mentioned it the first time, led to a bunch of seemingly pointless tests and a brusque encounter with a senior doctor at the local hospital who used me as a testing dummy for two interns (to show how to check for hernia) but didn’t answer my questions. I should get a colonoscopy, but I hated the man who did my last one and I don’t know how to find someone else. I’ve had several horrible experiences with dentists and so I haven’t seen one for four years. I don’t feel that there is any doctor I can even imagine who might have a sense of my overall health picture: everything about my experience of medical care is now fragmented.
A lot of this situation is my problem. It’s where I’m at, how I feel, it’s not the fault of the system. Other people around me with the same coverage either ask more aggressively for the services they want or take care of their own health more forthrightly. But some of the issue here for me is an issue of trust. I need to be able to trust what a doctor says to me, to trust that there will be an appropriate match between solution and problem. I don’t feel that I can, and I don’t feel I’m alone in that.
When I widen my awareness to friends and family in a variety of professional and life circumstances, the discomfort and uncertainty I feel about my relationship to a vast, complex health care system gains some additional elements. I have friends who have gone without coverage for significant portions of their life, living in fear about what might happen. I know people who cling to terrible jobs just to retain their health care. People who have thought they had coverage for something only to find that someone changed the rules on them and now they don’t. And yes, I’ve know people who have found fabulous doctors and surgeons and dentists and hospitals that they trust. I really like my daughter’s pediatricians, for example. (We needed to go to the Children’s Hospital of Philadelphia recently to have her seen about what turned to be a minor matter. I felt like a medieval serf who had only been to the local straw-thatched church before but was suddenly walking into Notre Dame.)
Some of what bothers me isn’t the structure of the system, it’s the culture of contemporary medicine, about how doctors are trained. I recoil intensely from all medical service each time I have an encounter with a brusque, unpleasant, hostile or incompetent medical professional. Being infantilized or treated like an assembly-line product is like nails on a blackboard for me.
Some of it is structural. Am I paranoid to wonder about whether a drug is being prescribed to me because I need it? To wonder if I really do need to lie in an MRI? To wonder which procedures I need and which I don’t? To wonder if my doctor actually is listening to me or is just finding the quickest way to diagnose and shove me out the door? Before I ever investigate the medical system with my mind, my heart senses that the incentive structure of the whole thing is wildly out of whack, that it’s not doing right by me, a person with adequate coverage, and even less so by almost everyone else. When I have to get a blood test in the local outpatient clinic, I’m sitting glumly with worried families who’ve had to come to the emergency room for basic medical care, whose encounters with the system are far more fragmented and anxiety-ridden than my worst nightmare.
What my heart senses is that it doesn’t have to be that way. I know what it costs my employer, because I’ve gotten a good look at the budget over a series of years: the costs have skyrocketed while the quality and form of the service product bought for that money has fallen. I know that my doctor and most doctors don’t like it any more than I do. That maybe even the insurers don’t like it.
But here we are, all helpless. All talking about the wrong things. All strangling in the poison of scoring points against each other in a game that long since stopped being real, that then became farce, and is now just a sick joke. My head isn’t involved: I’m not going to whip out a better ten-point policy plan or even pretend to care to have undying passion for single-payer or this plan or that initiative, to judiciously stroke my chin and puff my pipe while I commend the approach of Sweden or Singapore or Massachusetts.
It all feels wrong, not just health care but so much else. And I think I give up now any hope that it can become right in anything like a well-ordered, incremental process where the participants just want to do the right thing. What it is, it is.