Anxiety, Denial, Fantasy, Fear, and Hysteria Regarding Health Care Reform

Americans have had the fantasy—and many still do—that we have the best health care in the world. We certainly have the most expensive health care system, since nearly a sixth of our gross national product is devoted to it.¹ Yet about 46.3 million people are uninsured,² approximately 45,000 Americans die every year for lack of proper medical care,³ and 900,000 go bankrupt yearly as a consequence of medical bills,⁴ despite most having some medical insurance. While many separate aspects of our hodgepodge system are world class, by the standards of infant mortality rates, longevity, ease of use, recovery rates, healthy life expectancy after age 60, and cost, U.S. health care lags well behind those of the other highly developed rich nations. In this essay I will discuss the fantasies, fears, hysteria, and denial serving as a barrier to effective health care reform, and provide some psychohistorical insights regarding health care.

American Antipathy to Benefiting from the Examples of Foreign Health Systems

Although there are about 200 countries in the world, Americans often act as if other societies barely exist. American fantasies do require that there be some “bad countries” (Hitler’s Germany in WWII, Stalin’s Russia in the Cold War, Saddam Hussein’s Iraq, etc.) that need to be fought in the name of freedom and liberty; and some deserving “good countries” (France, Britain, and Stalin’s Russia in WWII; Iraq in the mind of our 43^rd President, etc.) to be saved from the external or internal “bad guys.” In many cases it is sufficient to simply give money to help the starving children of Africa (African countries are not differentiated by

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most Americans) and elsewhere. The rest of the world is a blur beyond being a vacation spot, a place to find inexpensive goods and cheap labor, or a source of loans to America to maintain our deficit spending.

Through the early stages of the health care reform debate, Obama’s call for transforming our system from the most expensive in the world—rated 37^th in terms of delivering life extension and wellness—has been crucified as a foreign anti-American socialist takeover which would destroy the last vestiges of our freedom while we wait endlessly for the ineffectual doctoring of bureaucratic medical staff.⁵ What is most striking is that American narcissism has allowed the opponents of reform to cloak the realities of health care in the rich developed countries in the ideology of laissez faire freedom versus totalitarian dictatorship. This essay is based upon a large variety of sources, with some specific information coming from The Healing of America: A Global Quest for Better, Cheaper and Fairer Healthcare (2009) by the former Washington Post journalist T.R. Reid, who excellently summarizes health care in America and around the world, although its approach is not at all psychological.

Throughout my life I have never trusted the ideology of either the right or the left. When it comes to health care this profound distrust is borne out by the facts. When I lived for two years under a socialist government, I was provided good health care despite the single provider and no consumer choice system. During my involuntary service in the Army at home and abroad this socialist system was established and paid for by the United States taxpayer. This is far from a rarity in America, where recipients of government health care include approximately 44 million elderly and disabled individuals currently on Medicare,⁶ about 42 million American children and poor families on Medicaid, and substantial, but much smaller, numbers of prisoners, Native Americans, and veterans.⁷ However, I have never been one of them since af-

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ter two years I wanted nothing more to do with the military.

A Health Care Debate Dominated by Fantasy Rather Than Reality

It has been utterly mind-boggling and at times mind-numbing to spend innumerable hours in August watching town meetings on the C-SPAN cable network in which large numbers of often gray-haired individuals denounce the attempts to achieve health reform by Obama and the Democrats as either the first or the final step to a socialist totalitarian form of government. Even at a town hall meeting held in a senior citizens’ facility where virtually everyone was on Medicare—a generally efficient low cost per patient government-run health care system—the participants were not very amenable to reform for fear of socialism or a loss of their own benefits. The Democratic and Republican Congress people seeking feedback and support from their constituents often found it difficult and even impossible to proceed because of staged disruptions including large signs of Barack Obama with a Hitler-like moustache.

A basic principal of psychohistory and psychoanalysis is to explore the emotional basis of fantasies, holding them up to the light of reality. Both personal and political fantasies can be incredibly persistent. For example, several years into the Iraq conflict an overwhelming majority of Americans continued to believe that Saddam Hussein was responsible for the 9/11 attacks in the United States.

Fantasies about government involvement in health care abound and typically involve little connection to reality. Below I will examine some of these that were prevalent at the August town hall meetings and throughout the discussion of possible reforms.

Some of the Problems with the Current American System of Health Care

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Most health insurance comes through employer-initiated programs. It is common for insurance companies to win their insurance bids by keeping the employee cost to a minimum through cutting corners, which makes some sense from their economic standpoint because employees are likely to change jobs and therefore insurance companies about every six years. In providing insurance to individuals and small employers, “cherry picking” is common-place. Only the healthy without existing medical conditions are signed up for the insurance—pregnancy counts as an existing condition from many of these insurers—and the insuree is either dropped or rates are skyrocketed up to a prohibitive level when significant claims are made. In short, when insurance coverage is needed the most is when it is most likely to be denied.

Insurance companies are also notorious for using delaying tactics rather than making payments directly. Delay of payment tactics can certainly work. For example, recently my wife almost paid a $425 bill from the beginning of this year because the confusing paperwork going back and forth between the provider and the insurance company made it appear that the coverage was denied, which was not the case. Insurance companies can certainly wear you down. This is a far cry from France, Italy, and Taiwan where the payments are made within the week. In Taiwan if the check is not mailed out within the week, the insured doesn’t need to pay for next month’s insurance as a penalty. There are numerous horror stories regarding the consequences of American insurance companies delaying or denying insurance, some of which end with the needless death of the insured.

My Personal Experience with Health Care

As a college professor I have much better than average health insurance. Unfortunately, over time my employer and insurers have effectively worked to lessen the benefits and increased my out-of-pocket costs. For decades my good

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health care coverage was appreciated as a compensation for relatively low salary for someone of my education, dedication to high standards, and achievements. In 1997, I was required to contribute a specific amount for the health insurance, beyond the usual yearly deductible and co-pays. (At the time I discovered had I signed up for a pension plan one year earlier, I would have been “grandfathered” into the traditional high quality, total consumer choice, no cost to me, Blue Cross Blue Shield, major medical plan!) Nevertheless, I was left with a better than average policy, for which I paid a moderate amount at first. Every year the cost of having this medical insurance plan increased, encouraging me to transfer to a Health Maintenance Organization (HMO). Early this year the choice of paying extra was taken away as I was forced into a plan which would cover only 70% rather than 80% of allowed customary charges—which are usually more than the going rate in the costly area where I live—unless I go to the doctors and laboratory affiliated with the plan. In these cases I would simply have a $15 co-pay. A definite advantage to their plan is that it covers preventative medicine such as yearly exams (but only at the hands of a doctor affiliated with the plan) and flu shots (again with designated doctors), which had always been an-out-of-pocket item.

Our dilemma became: do we stay with our family doctor who knows every nook and cranny of our bodies and pay more, or go to some doctor with whom we have no history and for whom I have no recommendation except that of my cost-cutting insurance company? The tightness of my stomach and rise in my blood pressure following even considering this possibility has several sources. First and foremost, I feel that my rights are being infringed upon and that I am being treated like a commodity shifted around for the benefit of the multi-billion dollar insurance industry. Profane thoughts start occupying my consciousness as I consider if I should stay with our fine internist, who was a colleague be-

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fore she opted for medical school and private practice, or be forced to change doctors to save money.

The lower costs to me of a Blue Cross Blue Shield-sponsored physician might be a pleasant surprise. As much as I personally respect and like my doctor, I can see some potential advantages beyond saving money: my physician’s memory is not as sharp as it once was and my paper file is so thick that it can be very time consuming to check something. If the new insurance-endorsed doctor has everything online the process can be very quick. I think of French doctors, who are without paper files, inserting the patient’s identity card that brings up their entire medical record. Also, perhaps these doctors will have the latest training that my friend has not had. (Although she is no Luddite, my physician refuses to have a computer in her office on the grounds it will distract from her direct contact with her patients.) However, will they look into my wife’s room at the hospital at 6:00 AM on a Sunday morning even though her admission and treatment were at the hands of another physician, like her? Positive experience, loyalty, not wanting to be pushed around by my insurance company, and a preference for keeping as much control as possible for my own medical care, convince me to pay more to stay with my trusted physician.

Fantasies about Health Care Feeding Popular Anxieties

Reviewing my own medical options helps me to understand more about the anxieties expressed by Americans regarding health care. As every psychoanalyst and politician knows, change is difficult. It is extremely dangerous for politicians since public anxiety can be mobilized to defeat change, as it was in 1993-1994 when Clinton’s health care program was blocked. Debunking myths is not easy especially when there are so many industries, peoples, and groups with their own vested economic, ideological, and psychological interest. Below, I will examine many of the myths,

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holding them up to the light of day. The primary myth is that if the government is involved in health care, it would take America down the road to socialism. (All the governments of the developed world have government health care and only some are socialist. Germany, which has government-mandated health care since the 19^th century has a conservative government, not a socialist one.)

Governmental involvement is by its very nature inefficient, and private insurance therefore is always more cost efficient than public insurance. (The reality is that government-run systems in other rich countries have much lower administrative costs than the private sectors of the U.S. health care industry.)

Other rich countries all have socialized medicine. (Actually, most national health care systems which Americans think of as socialized are not socialized at all since high levels of care are provided by private doctors, private hospitals, and private insurance plans with lots of choices.)

Americans would hate and have no choices in a government-run single payer health system. (In fact millions of Americans seem to like government-run systems since when they turn 65 they overwhelmingly switch to Medicare. In contrast, in Switzerland and Germany people keep their same private insurers regardless of their age.)

People under socialized medicine come to the U.S.A. for treatment because their system is so inferior. (Although Canada and Britain withhold some services, their populations strongly support these programs. Canadians think as many foreigners come to their country for free medical care as people in the U.S. believe Canadians go to the U.S. for health care. Both numbers are exaggerated.)

Countries with universal health care have far more withholding of service and longer patient waiting times than

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does the U.S. (In fact there is more withholding of services in the U.S. than in the other developed countries. While countries like Britain and Canada limit the number of specialists so there are problems with waiting times, in Denmark, France, Germany, Sweden, etc., there are shorter waiting times than in the U.S.A. In Japan, patients are inclined to not even bother making appointments because the waiting times are so short.

Under Obama “Death Commissions” would be established to determine who lives and who dies. (A pure fabrication meant to put the fear of death into those seeking reform.)

Illegal aliens would be covered under the Obama health plan. (The House bills explicitly prohibit this.)

Foreign systems all have bloated, costly bureaucracies. (The reality is that their systems are usually much less bureaucratic than that of the U.S., which is why a country like Japan, spending half of what the U.S.A. does on health care, has such markedly better results.)

The systems in foreign countries are too un-American to work here. This follows from the notion of American exceptionalism—the U.S. is different and implicitly better than the rest of the world. (Although America has a different history than much of the world, the way the idea of American exceptionalism is used often reflects a not so unique xenophobia. Experts from Harvard, Princeton, and other U.S. institutions have designed by some of the best health care-systems around the world. The main obstacles to reform in America have been a lack of political will combined with the Washington system of gridlock.)

Most of the myths about health care being bandied about this year are based upon fear of growing government involvement in society. The ideological fantasies exclude

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examining the present reality and the issue of what different proposals mean to real-life people—to say nothing of our federal, individual, state, and corporate budgets. Currently, the cost of a General Motors car includes $1,525 worth of health care expenses, while their foreign competitors directly pay nothing for the health care of their workers, giving them an unfair advantage. Conservative Republicans clearly lost the 2008 election, just as they lost the 1992 election, but they are determined to block an expansion of the social welfare aspect of government. During the massively deficit spending supported presidency of the second Bush, some conservative ideologues began to say that even Republicans could not be trusted with the national treasury, so that perhaps it is best if the government spends so much that it must cut out social programs. Throughout the year they have been organizing “tea parties,” representing the culmination of the strategy of curing big spending in national government. The “tea” in the “parties” refers to taking radical steps against taxation, as they recall our founders did with the direct action of the Boston Tea Party of 1773. (In fact a group of libertarians started the Boston Tea Party in 2006!) Thousands of conservatives and libertarians showed up for a Washington, DC, anti-health care-reform, anti-spending rally organized on September 12^th with former Republican Congressman Dick Armey as the most prominent speaker.

Prolonging the Process of Dying Versus Quality of Life in End of Life Care

American belief in technology and the impulse to deny the inevitability of death has led to fantasies of being able to postpone death indefinitely. But taking a long time to die is no way to live for most human beings. End of life decisions are not easy, but in our culture a number of factors combine to provide useless, inhumane, and expensive procedures postponing death, while creating a terrible life for the dying and their families. As Dr. Matthew Hayes puts it, the

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patient “often must experience the indignity of suffering the cascading failures of systems and organs; each in their turn, aggressively treated by another tube, through another orifice, natural or newly created” (personal communication, 9/28/09).

A number of factors combine to create this nightmarish situation. Doctors so often perceive the impending death of their patients as a personal failure, assuaging their guilty feelings and those of the families who are often in shock by taking some action, however useless. The hospitals benefit financially because the bill for this extension of dying is picked up by Medicare, the insurance companies, the patients, their estates, or their families. As I will illustrate with the example of John Caulfield, palliative medical care is much more humane than pursuing the model of preserving life at all costs in the hospital.

About one third of all Medicare funds go to end of life services, mostly for the last few days or months of life. For John Caulfield, a member of the Psychohistory Forum’s Advisory Board, Hospice was a lifesaving system, perhaps extending his life for two years. In his 82^nd year he felt that hospitalizations for his heart condition were “killing,” rather than helping him. The impersonality of the system overwhelmed him. On Hospice he stayed in the comfort of his home, except for rare emergencies, enjoying its peaceful quiet without medical intrusions. There he felt useful as he walked the dog, straightened the house, prepared dinner for his working wife, and enjoyed a social life with his family, while having the care of an empathetic doctor, nurse, and hospice worker—all of whom came to his home. Dealing with his health problems at home left him feeling that he had some control of his life and usefulness to his loved ones. When those who had not witnessed his struggles for health expected his death to be imminent upon his going on Hospice, those close to him recognized the life-extending quali-

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ties of the system for John. After two years, he, along with his family and friends, knew he was ready to relinquish life when his body was just too worn out. Of course, a person who felt certain that going on Hospice meant death for them rather than relief from aggressive medicine, would likely die much more quickly.

Some Psychological Reflections and Defense Mechanisms

It is distressing that there is virtually no public discussion of the psychological aspects of health care in the current debate. We cannot separate our bodies from our minds or our minds from our bodies. Both are incredibly complex and interconnected. The marvels of modern society and medicine come at a high price, a price that is not simply financial. Health care brings dependency issues to the fore. Health care patients, without regard to age and title, are stripped down to their bare skin like newborns and are dependent on others. They often feel stripped of their dignity and considerable money as well. Others take control of our bodies, perhaps leaving us feeling much as we did as small children: helpless—unable to care for our own needs—dependent, and afraid. Patients are called by first names by individuals often a fraction of their age. In the face of feeling infantilized, is it surprising that many avoid preventative or needed care?

How do people defend themselves against the uncertainties of health and the impersonality of the health care system? Some mechanisms of defense coming to mind are denial (“I never get sick.”), suppression (I know I must have cancer but I don’t want to think or do anything about it.”), intellectualization (“Of course I could get sick and that lump I have may be cancerous, but I would rather talk about health care policy than go back to the doctor.”), projection (“Yes, I love money, but doctors just want people to get medical checkups because they are all greedy, even those working in

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clinics.”), undoing (“I was dumb not to go to a doctor for 20 years, now I go every month even though all my docs, who don’t know about each other, say I only need come once a year.”), and regression (“Yesterday, the doc called and said I definitely have a fast growing cancer requiring an operation tomorrow morning, instead I am going to go to a Caribbean Island for a month and just sleep on the beach like I did as a kid.”).

Back in the early 1980s Henry Lawton and I organized a Saturday workshop on transference to institutions with papers by psychoanalysts who were also a lawyer, nun, and priest. The transference to hospitals and medical institutions is quite emotion-laden and powerful. Hospitals often evoke the feelings of the “good mother” who can heal and save you and sometimes the “bad mother” who can maim and kill you. My wife and some 1,800 other individuals volunteer at a local hospital precisely because they have a positive transference to it. Throughout most of history, transference feelings to hospitals were much more negative than they are today because these institutions were places where people were likely to die from high infection rates and shock prior to the use of anesthetics, antibiotics, antiseptics, and other lifesaving advances of modern medicine.

In America the transference to insurance companies is much more negative than to doctors, nurses, and medical technicians precisely because the mostly profit-making insurance companies set themselves up as gatekeepers to health care. Thus they can become the evil “other.” Despite their customer service representatives often having to finish each telephone conversion, politely asking if they may help you with anything else and then thanking you for using their services; gatekeepers are an obstacle. Last year, for reasons unknown to us, an insurance representative in communicating with the doctor’s office, attributed to us false and inflammatory statements about the surgeon who had performed a pro-

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cedure and was likely to perform another one. My speculation is that this individual was taking out her frustrations with her job, at having to say things by rote, and with whatever other issues she had, by enjoying the power of schadenfreude—the pleasure at the displeasure of others.

There is no question that our current health system often transfers power from the doctor, hospital, and patient to the insurer. This leaves the average person at the mercy of a typically low paid, medically uneducated employee of an anonymous insurance company. A friend who worked as an emergency room physician would find that insurers would attempt to block or delay vital treatment needed under exigent circumstances. So, when he and his colleagues should have been focused only on the medical needs of their patients, he would be on the telephone with the insurance company representative, demanding to know the individual’s name, identification number, medical training, and the supervisor’s name and identification number prior to slamming down the telephone and awaiting a call back from a supervisor who did not want to be sued. My friend is unusual in that he is virtually impossible to intimidate, is unfazed by confrontation, and prides himself on fighting for the rights of his patients.

If the U.S. insurance system were an individual it is tempting to see it as neurotic at best and psychotic at worst. A system set up to raise the maximum anxiety as it serves the narcissistic needs of companies staffed by people who may secretly be getting sadistic pleasure from their clients before ending their telephone calls with thanks for having called them and “Is there anything else we can do for you today?” It is a totally ulcerating process to get through the barriers established by the insurance companies starting with working past the machines answering your calls, and then repeating the same information when you actually get to speak to a representative. It is a system with about 25% administrative

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costs compared to 5% in France, and even less in Japan and Taiwan.

During the health care debate, the only psychological reference that I recall was on September 23, 2009 during the Senate Budget Committee hearings in which Republican Senator Jim Bunting of Kentucky used the wrong word and, with a sneer, referred to it as “a Fraudian Slip.”

The Goals of Health Reform versus the Reality of Washington Politics

It would be good if the U.S. could reform its health care system to make it more economical, efficient, patient/provider centered, and empathetic while improving its overall performance to provide the longer life expectancies, low infant mortality rates, and other health achievements of the systems in France, Japan, and most other developed countries. This certainly will not happen in the near future, if at all; indeed the Washington system of gridlock makes even the moderate goals of the Obama administration problematic.

There is a sharp contrast between what is needed for effective 2009 health care reform and the needs of the political process. Given the incredible complexity of the current system several years of analysis and debate would be optimal. However, the reality of politics is that if health care reform is not passed within the next six months, then it is virtually certain that there will be no reform under this administration. While denying it, the Republican leadership is hoping for a repeat of the 1993-94 Clinton health care failure, resulting in a Republican takeover of the House and Senate in the 1994 election. In contrast to the Clintons’ aborted efforts, Obama’s strategy has been to bring the major drug makers, insurance companies, and other substantial health care interests, as well as the Democratic congressional committee leaders, into the process of planning reform. Their presence increases the chances of a bill being passed while lessening the likelihood of profound changes being made.

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The current administration is unrealistically promising not to raise taxes or take away services while reforming the system. Some reasons for these misguided claims are that no major American health reform has paid for itself in the past, health use increases with availability, and the realities of the political “sausage making process” means that efficiencies will be lost as special interests receive benefits to gain their support or acquiescence. At this point of the congressional process, it appears that governmental power will be utilized to force most of the uninsured into private insurance plans. This would extend coverage, but not reduce costs, as a single payer alternate might.

The major fiscal problem with the hodgepodge of the U.S. health system is that the incentives are to spend more money for administration, doctors, end of life care, hospitals, insurance companies, and technology. These incentives keep driving up the cost of health care. Other developed countries have used either a single payer system or governmental regulation to hold down costs while achieving better medical results. Considerable progress can be made even without a complete overhaul of the U.S. health care system. It would help to avowedly accept universal access to health care as a human right rather than as something that is dependent upon one’s financial well-being, as is the case in other industrialized countries. A consequence of this approach would be an emphasis on less expensive prevention rather than on the more costly reparative care.

Conclusion

The incredible cost and inefficiency of the U.S. health care system has placed a great burden on our economy while leaving 45 million people without coverage despite some aspects of it being the best in the world. Since nearly a sixth of our gross national product is devoted to maintaining it at a time when our economy is in recession and facing increasingly intense competition from countries spending far less

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with much better results.

The enormous anxiety about change and ambivalence regarding reform have been fed by conservative ideology, fear—at times bordering on hysteria, massive denial, special interest groups, and a xenophobic disinclination to learn from the rest of the world. The annual 20,000 preventable deaths as a result of a lack of comprehensive and fair health care system and hundreds of thousands of bankruptcies due to the costs of health care are among those without the sufficient political power to make their voices heard. Psychological studies of why health and its care are so anxiety-producing can help us understand and assuage some of the resistance to change.

At present progress is being made toward making the system more comprehensive and less unfair; however, there is little indication, despite the President’s intentions, that run-away health care costs will be contained. We in America are all participant observers in the current struggle to change the system.

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