Hearts and Minds

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.

This entry was posted in Politics. Bookmark the permalink.

10 Responses to Hearts and Minds

  1. Roxie says:

    Longtime lurker, first-time commenter. Thank you so much for such a thoughtful, eloquent articulation of what the current political moment feels like. A lot of folks have spilled a lot of ink (actual or virtual) lately trying to get at similar things, but you convey the sense of malaise and heartbreak beautifully and with considerable bravery. Thank you.

  2. north says:

    I have the same sense, though for me the worries are more immediate: I have insurance as long as I’m a graduate student, but my partner is in the individual market; we just moved, and the idea of trying to find a doctor or a dentist before it’s an emergency just makes me feel itchy and sweaty from anticipating the bad interactions I’ll have to have before I find someone good.

    On a more practical note, if you’re willing to go to Philadelphia to see the doctor, I really loved my primary care doctor at Spruce Internal Medicine (which incidentally is where almost all of my friends there went, and worked out really well for all of us). Everyone I saw in the practice listened pretty well, though I have not always loved the specialists they suggested. As a bonus, their phlebotomists are awesome.

  3. ikl says:

    Really??? Generally, I love your blog, but I think that this post on this day is sort of embarrassing.

    There is a bill in Congress that would provide health insurance coverage for 30 million Americans. All it needs is for the House (which already approved a more ambitious bill) to vote on it. We are this close. It is not perfect, but it would make a real difference in the lives of many, many people in our country without health insurance and do something to make our system more rational in a myriad of small ways.

    Many blogs that I read have posts up telling people to call their Congressperson and tell them to pass the bill (which I have done). Even blogs that have not been especially supportive of the Senate bill in the past. Why? Because this is it. We are either going to get something important now or we aren’t going to get anything. Because after this, it sure looks like we are in for years and years of either total gridlock or BS compromises that don’t really solve anything. It’s not time or Monday morning quarterbacking. Or griping about the Repubicans. Or depressed cynicism. There is a rare chance here to actually achieve something lasting.

    In the next several weeks, either something important for the country and for millions of people without health insurance will happen or it wouldn’t. After that, whatever happens with the health care bill, I predict you will have years and years for these sort of ruminations. With which I will probably nod sadly in agreement. But now is not the time.

  4. Timothy Burke says:

    I guess I wasn’t clear. I think it ought to be passed. But I also think from the very beginning the bill suffered from a lack of clarity, vision and ambition and got worse as it made its way through the legislative process. I do blame the ninnies who’ve been running around screaming that the bill is socialism and all that rot. But I don’t blame people who’ve found it difficult to understand how the bill is actually going to address the myriad ways in which American health care is a broken, dysfunctional system. Promises that this is the camel’s nose in the tent, and that it’ll permit improvements later strike me as unconvincing at best.

    But what I think ought to happen with the bill and what I think is going to happen is also different. Sorry if you think depression is premature. I think it’s the structural fact of the situation we find ourselves in, and the reasons go far beyond the wretched timidity of Democrats and the foul, cynical opportunism of Republicans. It wasn’t unreasonable to hope in early 2009 that things might have shifted not just at the level of leadership but in the underlying structure of American politics. It is unreasonable to hope that now.

  5. I don?? blame people who??e found it difficult to understand how the bill is actually going to address the myriad ways in which American health care is a broken, dysfunctional system. Promises that this is the camel?? nose in the tent, and that it??l permit improvements later strike me as unconvincing at best….It wasn?? unreasonable to hope in early 2009 that things might have shifted not just at the level of leadership but in the underlying structure of American politics. It is unreasonable to hope that now.

    I don’t think I’ve read a comment quite so fatalistic as this from you, Tim; indeed, during the worst depths of the Bush presidency–say 2003 to 2005–you were never fatalistic: you were angry, raging in fact, and threw yourself into diagnosing and explaining (to yourself and your readers) the hows and whys of the situation as you understood it. Of course, that was years ago, and time goes by and a lot of water flows under the bridge. Still, it’s worth reflecting on why the “underlying structure of American politics” seem hopeless to you now, when apparently it didn’t so strike you even after Bush and the Republicans did well in the 2004 midterms. (There was quite a bit of fatalism in the blogosphere pack then; I remember Teresa Nielsen Hayden’s reaction: “Well, 220 years is a pretty good run for a republic.”)

    I don’t deny that, as always, you eloquantly express a sensation which I–and no doubt many others who are basically comfortable with our places within the current socio-economic system(s)–have as well: the suspicion that the corruption, the inability to surmount the dominant ideological and rhetorical categorization of our political expressions, the intractability of the power of money and influence and self-interest, is simply too great to contemplate escaping. But isn’t it possible that we feel this way mostly because Obama and the move towards health care reform and much else promised something that, as much as we might wish to present ourselves as unflappable and worldly wise, nonetheless wanted to believe in, wanted to see happen? That the hopelessness of our entrenched, complex, patterns of compromise and division loom larger now, because we thought we could actually perceive a path outside of them? In which case, the Tea Partiers did much worse than merely sling mud at what started out as a well-intentioned bill.

  6. Timothy Burke says:

    When the conditions are poor, you imagine that if the conditions changed, good things could happen. When the conditions appear to have changed, and you’re surrounded by most of the same deep-seated kinds of failure, you have to take stock about what you thought were the limiting conditions at an earlier date.

    Beyond that, my feeling in 2004 was that some kinds of understandings were possible across what I suspected were highly manipulated and misrepresented divides in the public sphere and the body politic. I increasingly just don’t think that, because the conversation doesn’t seem to be re-converging at any point, and in many cases, is spiralling away into a flailing mess of idee fixes which don’t seem to bear any relationship to the world as I see it. I was just talking to my very conservative mother-in-law last night and she asked me if I’d seen this man called Glenn Beck. She said she was so impressed with his detailed command over facts and evidence, that he did so much research. I just don’t know what to say any more, you know? What’s the point of disagreeing with anyone? Who is in any sense persuadable or willing to be persuaded? All that’s left is the social underpinnings of why people feel as they do, which I completely agree are important and authentic and worth taking seriously. But the proposition that there’s some communicative connection that can happen, that the content of speech and ideas isn’t *just* a projection of a habitus, that we can somehow connect the hubs and spokes of a social network and make something that links the situated knowledges of people to systematic improvements in our institutions? It just seems like a stupid thing to have ever believed that possible.

  7. back40 says:

    I wish that this did not make you sad. I see the things you cite but don’t find these very human behaviors to be a cause for regret. We muddle through. By walking out of lockstep we make a motley crowd, but we avoid the disasters that come from uniformity. It’s nature’s way.

    As a quasi-naturalist working on the land this has a sort of beauty to my eye. It is more resilient in the face of inevitable and repeated shocks. Perhaps this is in the end an aesthetic issue. I see beauty in diversity. A mixed environment with many species at every stage of development is more pleasing to my eye than uniformity, even the ugly bits where some convulsion has just wrecked things, since I anticipate the new growth that will colonize that spot now that it is available.

  8. nord says:

    re your # 3, take heart – here is an issue that is not front of mind for any but a very narrow set of business interests, fighting it out in legislative chambers across this country and in Harrisburg this week: should new building codes require fire suppression sprinklers in all new residential construction?

    On the pro-side: sprinkler manufacturers, thier “experts” and some fire fighters.
    On the con-side: home builders, their “experts”, and the fire alarm manufacturing industry, which has surprisingly little overlap with sprinkler manufacturers …

    The science? Somewhere in the middle, but like any cost-benefit analysis, one that can be easily skewed by either side depending on initial assumptions.

    Just think, there are literally ten of thousands of people fighting over this issue nationwide as you read this. I assure you, the venom spit over this last month in Harrisburg is as bad as any of the healthcare debates in Washington, except the general public doesn’t care … helps put your little healthcare concerns in perspective. As i speak, the outcome is uncertain …

  9. AndrewSshi says:

    Tim, as someone who has talked to ornery retired relatives who tend to regurgitate FNC, I feel your pain. But especially since you teach courses on popular conceptions of academia, shouldn’t you be a wee bit more forgiving towards folks who are dazzled by a superficial display of what looks like citing one’s sources and backign up assertions with facts? There’s a reason that even folks peddling theories that are barking mad footnote up their books like crazy: it lends their argument the appearance, if not the substance of rigorous argument.

    On a side note, the only reason that I tend to go to doctors over the last decade and a half has been sports medicine, and I’ve tended to find it a wonderful experience–I get the vibe of, “We’re going to find what’s wrong and fix it.” I don’t care if I’m being treated like I’m on an assembly line if it’s an efficiently run one.

  10. hestal says:

    The physician encounters and the HMO plan that you describe did not happen by accident. There was a time, not so long ago, when HMO’s did not exist. I offered products and services to HMO’s for many years and I watched them grow, experiment, and learn. And throughout the process the one thing that was constant was: profit is all that matters.

    I can also remember a time when old people did not have health insurance. It was hard to watch. As luck would have it, I was on the team that developed the first, and most widely used, Medicare System. I realized how lucky I would be when I reached age 65 because I would have good health insurance. Niow I have it and it is better, by far, than the employer plans, the HMO’s, and the self-insured plans I had before Medicare.

    But now the folks who are under age 65 but above age 50 are falling into the slot once occupied by us old folks. Of course they had the same problem before Medicare, except costs were not so killing. These folks are in trouble and it ain’t gonna get better.

    The corruption in our national government is not new, as you accurately pointed out, but it is more dangerous. We aren’t fiddling with whether to outlaw cigarettes, which we didn’t, but we are fiddling with the very air we breath. The SCOTUS decision gives the tyranno-rulers of our world all the freedom they need to exploit every last resource we have including working people. We are fiddling with life and death for millions of people in a way that makes early death more likely than not.

    You should be very concerned. Passing health insurance reform as it is now generally configured will help lots of people, but many more will be disappointed and the stranglehold of the health insurance companies on the future of our nation will be stronger. They are on their way to control of the entire medical structure. Docs will be employees. Hell, they even may control medical schools. There is no stopping their ambition. Especially with the corrupt government we now have.

Comments are closed.