I am always amused by questionnaires designed to reveal whether we have enough money to last a lifetime. They are intended to help us plan for retirement. Yes, many of you are too young to worry about this, but humor me. One of the questions is some version of “How long are you going to live.” Another asks, “How much money do you expect to spend each year (for the rest of your life)?” Those questions are often enough to make us stop trying to fill out the form. Why?
Because we don’t know and it’s too scary to think about.
Which brings up the problem of choosing a medical or health insurance policy. I will use the words “medical” and “health” interchangeably to describe this insurance. I intend to target only two aspects of making a choice of health coverage, each of which follows from the questions above.
- We can’t predict how much health insurance we will need because we lack a crystal ball about our future health.
- Both psychological and intellectual roadblocks make it difficult to choose a policy. Thinking about illness and death, hospitals and doctors, is scary.
Despite all the words spoken about health insurance in the USA, no one discusses these two points and how they complicate the debate over what should be the federal government’s role, if any, in providing medical insurance for citizens.
I am therefore taking on the job. Again, humor me. This is important.
Lots of adults in the USA still get medical insurance from an employer, who might also insure the spouse and children. Most of you in the rest of the Western World receive government sponsored evaluation and treatment. But, historically speaking (if you are not disabled or “low-income”), in my country there are three choices other than a plan for which the employer pays a big chunk:
- Decide you don’t need or can’t afford medical insurance.
- Buy a policy on your own, one sold by an association (for example, by your college’s alumni program), or one offered in your state-run online marketplace.
- If you are a senior, sign up for Medicare, which is the coverage you get if your employer deducted a portion of your salary to make you eligible once you were old enough.
Our politics is dominated by the question of who makes the choice. Are you free not to buy medical insurance? Are you free to choose the kind of policy you want? One that pays for nearly all medical/psychological conditions or only some? Are you free to assume you won’t need certain medical/psychological services?
Some of the voices in this argument imply this is a rational choice, much like deciding whether you want to buy a car or prefer public transportation; and, if you do want a car, what model might you enjoy and how much are you willing to pay.
In fact, however, the decision is more complicated and not fully rational. Philosophers such as Martin Heidegger, a sociologist named Ernest Becker, and psychologists Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski have raised the issue of our discomfort with even the idea of mortality, let alone facing the reality of serious disease. Moreover, those social scientists created a body of research demonstrating our unconscious flight from the terror of our own personal end. No wonder Ernest Becker called his Pulitzer Prize winning book, The Denial of Death. No wonder the three psychologists do research on Terror Management Theory: not about terrorism, but the terror of knowing you will someday die.
Are you still reading or have you thrown a sheet over your computer screen?
If we cannot frankly face death without a secret shiver and a turning away, how then can we make rational choices about what health care we need or will need?
Will you or your child get depressed, need psychotherapy, or psychotropic medication? Become addicted? Have an accident? Face an unplanned pregnancy and need maternity and pediatric care? Be taken to the ER? Require a vaccination? Encounter a chronic, expensive illness?
No crystal ball, eh?
Few people seek out these unwelcome thoughts. We put them out of our minds when our health is good. Indeed, we must surely have inherited the ability to distract ourselves from life’s dystopian downside. Had our ancestors, broadly speaking, not had such an attitude, they wouldn’t have survived and we wouldn’t be here. They needed to attend to all the immediate tasks of living. “What if I get sick?” was not the most helpful question when the crops needed planting and harvesting.
A certain bravery is to be found in this optimism toward life. The attitude must come from half of our species, the fair sex bearing our children; those who (to quote W.E.B. DuBois) risked their lives and bodies “to win a life, and won.”
Illness and mortality are prospects most of us compartmentalize unless we are battling them. We will acknowledge the concerns, but in an abstract, impersonal way. They are “out there,” or “might happen someday,” but not today. We give these inevitabilities their own separate room within our psychic space, building the structure with bricks and mortar, double thick, the more to keep our emotions and thoughts untroubled. We wall-off potential weaknesses of our psyche and flesh, put them in isolation where we cannot be turned to stone by the prospect of serious illness, as if we faced Medusa.
My office manager routinely checked insurance benefits for new patients when I was in practice. Why? Because they usually did not know about their coverage. Some, in fact, were saddened and surprised to discover they had no therapy benefits and their insurance paid only for physical issues; that is, until the law required attention to mental illness.
Understand, please, my patients were almost all of average or greater intelligence. Still, most lacked knowledge of potential holes in what they considered to be their healthcare safety net. They trusted they were “well-covered.” Perhaps an insurance salesman told them so or their employer did the same. Or, maybe, after the Affordable Care Act (Obamacare) became law, someone assured them therapy was among the “essential health benefits” in their insurance contract. In the latter case, they did, indeed, have counseling benefits. Again, however, they tended not to know the details.
We live, as humanity always has, in a world requiring a significant amount of faith in other people. What I’m getting at, however, is more than trusting whoever designed your insurance or whoever is offering the product. In order to make thoughtful decisions about medical insurance we must face the issue of illness and mortality squarely, without evasion or distraction; and with a level of experience, intellect, and even specialized knowledge to do the job. We must do this despite our tendency toward mental and emotional evasion of illness and death.
To quote the title of a Tom Stoppard play, what we have here is The Hard Problem.
The top image is a Saddlebred Stallion in Harness by Jean. Balloons in a Car Lot in Normal, Illinois, by ParentingPatch, is followed by Caravaggio’s The Head of Medusa. All are sourced from Wikimedia Commons.
Having worked as a nurse and carer to the elderly for the last 15years has kept this reality in the front of my mind. Those who keep themselves in denial seem to be the worst off and in the end don’t cope. Because of their refusal to make decisions about there aged care inevitably the decision has to be made for them and often to suit the family rather than the recipient of care, they feel this has been forced on them and that their family have left them in a nursing home and feel unloved. To own the truth that is the case because no open discussion has happened in the family, adult children are overwhelmed with the decision making as well as the family crisis happening when they still have to work and raise kids or face their own family isssues and a lack of understanding of options, the end result is often undesirable to all concerned.
This is where I think the world of my own grandmother who, when the time came that she was struggling on her own chose to go into nursing care. She had time to prepare and sell her home, chose her own nursing home, even her own room. All the extended family was included in helping with these arrangements. We had about 3 good years with her health, and since she chose a nursing home central to most of the family was visited just about every day by someone (my days for visiting was Wednesdays) and when the time that her health really started failing,we as a family could just focus on her care and not be overwhelmed. It was the greatest gift she gave our family and an incredible act of love. We could talk about her wishes regarding her health and approaching death, in fact, I was able to ask her what she wanted in case something happened like a stroke, whether she wanted to be taken to hospital and have possible invasive treatment, and she said ‘no, I’ve lived a good life, I would be happy to go, I think Grandpa would be waiting for me on the other side with a cup of tea’. So six weeks later when she did have a major stroke we could just be with her until she past.
In my experience she was a rare gem, I marvel at her wisdom and love. And she will always stay close to my heart until I see her again and give her a big hug
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A wise and brave woman, indeed, Claire. Thanks for sharing a bit of your grandmother’s life.
Your grandmother was a wise woman. When my time comes, I hope that I will be able to make the same wise decisions.
I think perhaps once before I may have referenced the book The Worm at the Core by Solomon, Greenberg, and Pyszczynski. It is a remarkable book that carries on Ernest Becker’s work and provides evidence that fear of death guides our thoughts and actions. I have read it a couple times and very much appreciate their take on death. It is very readable, thought provoking, and, yes, includes some levity. This might be a good time to read it again. Here’s a link:
I appreciate the complicated issue of health insurance yet I still think that, in a responsible society, we need to take of each other. Health care should be a right for all citizens. I was also grateful that the ACA gave parity to mental and physical health. It was/is high time that the culture recognizes that mental health needs to be addressed in the same manner that a broken bone or cancer need to be addressed. Individuals and communities suffer when mental health is not a priority.
Thanks for the interesting post. And, just in case you were wondering….. we had a lot of rain again this past week in NorCal but the forecast says some breezy blue sky kind of days coming up this week. Hallelujah!
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Glad the weather suits you, JT! Thank you for posting the link. You did mention it previously and prompted me to read it, though I knew of their work prior. It even takes a bit of courage to read it, though I think the authors have done a great job of keeping a dark subject approachable and, as you say, occasionally amusing.
Well written and inciteful as always, Gerry! As I recall, before the ACA, business people were designing coverage — probably profit-based decisions, rather than the prophetic ones you spoke of based on need.
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Thanks, Judy. In the USA, as has been said by many people going at least back to Tocqueville in “Democracy in America” and Max Weber in “The Protestant Ethic and the Spirit of Capitalism,” there is a powerful financial incentive here. One can argue the value of that incentive both ways: on one side Frederick Hayek and on the other Karl Marx. Their opinions still resonate in the public square today, though they have morphed some on both sides. Whether health care should also be subject to the same rules as car sales, more or less, continues to divide left and right. I can only say that those who have strong opinions about this should do what they can to influence the debate. If they do not, someone else will.
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Another problem with healthcare insurance is that not all local providers may accept your insurance. Some people have to travel great lengths to get care. Additionally, regarding mental health care, the public still has trouble differentiating between a psychiatrist and a psychologist, and most people are unaware that there are many different orientations that go with the myriad titles mental health professionals hold, such as PhD, PsyD, MFT, LCSW, LPC, and “life coach.” It can be confusing to find a provider let alone a healthcare plan that would cover your mental health needs.
Thank you for your comment. Indeed, there are many problems with the state of our country’s provision of health care and the health insurance that plays so big a part. You are absolutely right about the confusion over different types of therapists. I tried to simplify the argument in this essay by focusing very narrowly on a portion of the difficulty about which little or nothing has been said. I certainly agree with you that the problem is much larger.
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Dr. Stein, thanks for tackling what is for me a stressful subject of medical insurance.
Based on your earlier recommendation, I’m currently reading Becker’s book on The Denial of Death. It’s extremely enlightening.
I’m delighted to hear that you are giving “The Denial of Death” a chance, Rosaliene. It does explain a lot of what we humans do, doesn’t it.
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It sure does. Some things, like ‘transference,’ are very scary.
I came across this article this morning which immediately tripped my mind back to your last post:
“Nothingness: That is what we’re trying to wave away when we reach for our phones in line at the grocery store, and when the obtrusive music played during a meal rescues us from what would otherwise be an excruciatingly awkward silence.”
Right in line with Becker, et al
Thanks for this excellent piece, JT. I suppose it’s actually Becker who is in line with Heidegger! I’ve also had a bit of experience with those who attempt mindfulness meditation and stop almost immediately. Granted, it is a hard practice, but perhaps the intruding world of both mortal and everyday fears (which often amount to the same thing) are just too much. Thanks again for the link.
True , Becker is supporting Heidegger ! And, funny thing on the mindfulness meditation… as a young college person in 1972 I paid my big bucks (I think it was $75 which was quite a fortune for me at the time) to get trained (indoctrinated?) in Transcendental Meditation – all the rage on college campuses in California at that time. I stuck with it for about a year and a half and then I started letting go of it. It was just too hard to do. About ten years ago when mindfulness meditation became the thing, I just refreshed my memory about TM and started a daily 20 minute practice. I have been largely faithful to that practice with occasional slumps but, especially since retirement about 18 months ago, I have actually come to look forward to that 20 minutes. I practice first thing in the morning (generally around 4:30) when the house and neighborhood are still. Some days it is a battle of sorts. I cannot find that calm place. Occasionally and more frequently though I DO find that calm place and that’s why I continue. I never know for sure what the day’s practice will bring. I think it’s interesting that I appreciate the practice more now as an older person. What changed? Life is not so frenetic? That doesn’t really work though b/c life in my head is still often frenetic. Who knows? Maybe I’m just more tired? Or don’t care as much?
I liked the Woody Allen quote. I often ask myself why I bother to get up in the morning. I can relate so much to “what’s the point?” since it’s all going to end in nothingness. BUT, I do know that I am eventually going to get up and I am going to do whatever the responsible thing is to do that day so I might as well get up early and do two things that I enjoy: 1) that 20 minute meditation practice and 2) a 45-60 minute walk with the dog in the neighborhood. After that? I will move through the day and see what is waiting for me even if I can’t figure out what’s the point!
Opening day for SF Giants tomorrow – and now there’s a reason to get up, right?
I didn’t know or had forgotten you were a baseball fan. The Giants are a great team. If you are into baseball antiquity, there is a book about the 1951 season of “The Miracle on Coogan’s Bluff” and “The Shot Heard Round the World” called “The Echoing Green,” which details the electronic sign-stealing that advantaged the Giants and may have enabled Bobby Thompson to know what type of pitch Ralph Branca was throwing in the fateful last at-bat. But the greatest baseball book I’ve ever read is “The Glory of Their Times” by Lawrence Ritter, an oral history of the men who played the game in the first two or three decades of the 20th century.
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Another thought, JT. This is a quote from a 2010 Woody Allen interview: “You start to think, when you’re younger, how important everything is and how things have to go right—your job, your career, your life, your choices, and all of that. Then, after a while, you start to realise that – I’m talking the big picture here – eventually you die, and eventually the sun burns out and the earth is gone, and eventually all the stars and all the planets in the entire universe go, disappear, and nothing is left at all. Nothing – Shakespeare and Beethoven and Michelangelo gone. And you think to yourself that there’s a lot of noise and sound and fury – and where’s it going? It’s not going any place… Now, you can’t actually live your life like that, because if you do you just sit there and – why do anything? Why get up in the morning and do anything? So I think it’s the job of the artist to try and figure out why, given this terrible fact, you want to go on living.”
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Grew up following the Dodger Blue but turned my allegiance to the Giants when I left for college in the SF Bay area with NO intention of ever returning to the greater Lost Angles area. It’s been fu to be a Giants fan! There are a couple of great role models for kids on that team too!