Understanding the Irrationality of the American Health Care System

Let me start with the personal story of how I came to be involved with the issue of health care policy and attempting to change it. I am a psychoanalyst and psychotherapist, and have been in full time private practice in Western Massachusetts since 1977. From the beginning, and continuing to the present, I have been a “provider” for any and all health insurance companies who “covered” the people who live in my area. Initially, my primary motive for doing this was to

Page 240

generate income. However, even after my practice was secure and well-supplied with referrals, I continue to maintain my contracts with the insurance companies, mostly because I believe that my services should be available to the public at large and not just to those who can afford to pay psychotherapy fees out of pocket. Starting in the mid-1980’s, and increasing in strength and presence since then, therapists and Americans have had the phenomenon of managed care paying all or a large part of the patients’ fees, but at the cost of dealing with a variety of severe intrusions on the treatment.

Unlike many psychotherapists, who terminated their insurance contracts when managed care took over, I chose to stay a “provider” because I felt that not being able to work with large segments of the population was worse than making the accommodations necessary to treat patients within the restrictions imposed by managed care. However, I did become quite actively involved with several organizations of psychotherapists, psychologists, and “consumers” which were trying to undo, or at least ameliorate, some of the depredations brought on by managed care. A number of us tried diligently for years to attempt to work legislatively and legally, as well as to try to negotiate directly, with the insurance companies. All of these efforts were notably unsuccessful.

Sometime around 2003, it became clear to me that the only way managed care could be reined in or eliminated was through a fundamental change in the way health care was paid for in this country. Since mental health was only a small part of the 2.4 trillion dollar health care industry and was well embedded within the larger medical reimbursement system (MSNBC 3/12/09 Report, see http://www.msnbc.msn.com/id/29641091/), major change would have to involve the entire health care financing system. The power of the insurance corporations would have to be challenged and reversed. They would have to be either eliminated or severely limited and regulated. The most direct method

Page 241

would be to adopt a universal government-run single payer system. Consequently, I joined Physicians for a National Health Program (PNHP), as well as several other single payer groups, and have spent a good deal of time since 2003 trying to master some of the complexities of health care policy and finance in this country.

This is all by way of introduction to writing about a psychohistorical account of health care policy and the current reform process. Although the essence of a psychohistorical view is to understand the psychological motives and processes crucial to comprehending past and present group behavior, we must also consider the political, historical, and economic elements. If we want to say something about what is irrational about health care policy and the current reform debates, we need to know something of the rational side of the issue.

As a starting point, consider that the vast majority of people who thoughtfully and disinterestedly examine health care policy conclude that some form of what is known as a single-payer system is the option that makes the most sense. This statement applies only to those who are both knowledgeable in the area and do not have a significant financial stake in the health care status quo. It also does not apply to free market advocates who believe that the private for-profit sector always does things better than the government or a non-profit.

Virtually every country in the developed world, other than the United States, has some variant of a single payer system. This country spends far more per capita (more than twice as much compared to many others) than any other country in the world and with mediocre health care outcomes. The latest numbers have us ranked behind other developed countries in population health care outcomes, such as life expectancy and infant mortality.

Page 242

There are many arguments for the superiority of a single-payer system. The two most powerful are that it eliminates two-thirds of the roughly 31% overhead (dollars not spent on actual health care services) generated by the administrative complexity of our current fragmented multi-payer private insurance company system, for an annual savings of around $400 billion; and because a single payer entity has enormous market power (David U. Himmelstein, “Costs of Health Care Administration in the United States and Canada,” New England Journal of Medicine. Vol. 349: pp. 768-775 No. 8, August 21, 2003. See <http://content.nejm.org/cgi/content/full/349/8/768>). As the sole purchaser of health goods and services, it is in a position to force all of its suppliers, from pharmaceutical companies and medical device makers to medical service providers, to sell their goods and services at the lowest possible price. This generates large additional savings and builds in a very powerful cost control mechanism.

The health care industry has become a major political force in Washington, which helps to explain the rapid increase in costs. Their interest in profits is placed before those of the insured and the cost containment interests of the public, thus contributing to the economic irrationality of the system. The level of irrationality in the current debate on health care has reached a point best described as hysterical. There is also latent racism in the attack on “Obamacare”.

There are many sources of this irrationality, but here I will focus on its basis in the belief system, ideology, and ultimately the group fantasy, which appears to have a powerful grip on the population of this country. I would characterize this fantastical belief system as American exceptionalist libertarianism. At its heart is the conviction that this nation and its people both value and embody “freedom,” more than any other nation or people. This fantasy is clearly quite narcissistic. We Americans are special; we are the land of the free.

Page 243

Professional historians have long discussed the thesis of “American Exceptionalism” to characterize a variety of beliefs and behaviors exhibited by this country going back to pre-revolutionary times. Although the core meaning of this libertarian credo is that individuals should be as free as possible to pursue whatever it is that makes them happy, it has been extended to apply to business ventures and corporations. They too must be allowed the unfettered pursuit of their goals—primarily to make money.

This freedom, for both individuals and corporations, to do what they want is contrasted to public or even more strongly to governmental structures, which are seen as restricting this freedom. In the health care debate, those influenced by this libertarian ideology eliminate a single payer system a priori because it is governmental or closely regulated by the government

This is precisely what has happened during the recent deliberations of Max Baucus’ Senate Finance Committee during which some dozen “stakeholders” were literally invited to sit around the table to discuss the provisions of the reform bill. Included, among others, were representatives of hospitals, drug companies, physicians, health insurance plans, some labor unions, and the chamber of commerce. However, there was not a single-payer supporter amongst them. When some PNHP physicians showed up to speak at a public hearing of the Committee to advocate for a single payer system, protesting the exclusion of representatives of their position, the police were called to forcibly remove them from the hearing room and they were arrested.

The subtler, and in some ways more dangerous, element is the power and pervasiveness of the predominant group fantasy/belief system in this country. Even among people who are aware of the obvious superiority of single payer, many will not actively fight and advocate for it because they recognize and acknowledge, and perhaps share a

Page 244

bit of it themselves, the hold that this fantasy has on the American people at this point in our country’s history. These are the people, like President Barack Obama and the New York Times columnist Paul Krugman, who say things like “if we were starting from scratch” or “in the best of all possible worlds” we would have single payer, but then add that “politically” it is just not feasible. Perhaps it is a case of a self-fulfilling prophecy.

We have seen the most virulent and hateful aspect of this libertarian fantasy in the various right wing flights of political imagination loosed by Rush Limbaugh, Glenn Beck, and at the health care town meetings last summer. The right wing inspired fear mongering—”death panels,” mandatory abortion, socialized medicine, drastic cuts in Medicare benefits, rationed care, etc.—is the most obvious form it takes. In general, the diatribes of the extreme right wing are an excellent source of psychohistorical data as they express, in a relatively uninhibited and uncensored fashion, fantasies that allow us a glimpse of the most primitive and raw fears and wishes that drive the group. With regard to health care, fears seem to be mostly about government intrusion with its imagined threat to one’s freedom to choose one’s medical care. A variant on this is the fear that we will have to pay more in taxes, and therefore there will be less freedom of choice on how to spend our money.

There is also an extreme reluctance to put health insurance companies out of business, which would happen under a single payer system, because this would curtail the freedom of business entities to pursue their sacred right to make a profit.

Right wing ideologues are still a statistical minority, but the American exceptionalist libertarian group fantasy has many mainstream adherents. Their affect and rhetoric may be more tightly modulated and there is a veneer of rational argument, but there is far more similarity than difference be-

Page 245

tween right-wingers and centrists who share an allegiance to this position. The Democratic Leadership Council (DLC), a group whose mission statement emphasizes its belief in the virtues of free enterprise, free markets, and private business, may not be overtly anti-government, but they are very comfortable with the notion that private insurance companies can do a better job than a government single-payer system in providing quality health care at affordable prices.

Another issue of psychohistorical relevance is the question of why health care reform is such a lightning rod for this primary process (to use a psychoanalytical term for unfiltered emotion) outpouring from the right. There are doubtlessly many possible explanations for this as well as for what anxieties lie beneath all the virulence and irrationality. There is the heightened anxiety that can arise when death fears are activated, when the integrity of one’s body is threatened by illness or injury, as well as fears of intrusion and penetration, dependency, and loss of control that are connected to receiving health care from others.

In my opinion, one of the factors that make health care financing policy such a target and magnet for paranoid projections is its extreme complexity and ambiguity. From a psychoanalytic point of view, the more ambiguous the stimulus material presented, the more room there is for people to respond to the stimulus by projecting their own fears and wishes onto the material. This is the basis of projective testing, as in the Rorschach.

A related aspect of the explanation for the right wing tirade against health care reform is that this complexity and ambiguity creates an opportunity for disinformation and misinformation to be spread by those with their own agendas. These agendas can be financial—as in the lobbying and publicity campaigns paid for by the various financial stakeholders in the current system, insurance, drug, and numerous other companies. Yet these agendas can also be ideological—as

Page 246

when conservatives, libertarians, and privatization advocates use opposition to meaningful health care reform to promote their anti-government, pro-business agenda.

To psychohistorically understand conservative reactions to health care and the policy reform debate we need to look at the effects of an important current group fantasy, belief system, and ideology, which I am calling American exceptionalist libertarianism. It has led to a vehement attack on reform proposals that might challenge the hegemony of privatized health care by feeding fears that it would threaten freedom.

Although such a psychohistorical explanation has its appeal, I still do not know whether its influence outweighs that of old-fashioned, naked financial self-interest. For example, does Senator Max Baucus’ antipathy toward single-payer have more to do with being a true believer in the magic of the marketplace or with the large campaign contributions he has received from the health care industry? Both economic and psychological approaches provide vital insights.

Page 247