What No One Mentions about Health Insurance

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.

Simply put:

  1. We can’t predict how much health insurance we will need because we lack a crystal ball about our future health.
  2. 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:

  1. Decide you don’t need or can’t afford medical insurance.
  2. 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.
  3. 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.

When Your Doctor Gives You the Finger: Why Men Fear “Digital” Medicine

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The current medical rage is the move to electronic medical records (EMR) and the digital practice of medicine. But I’d like to say a few words about some rather different digits. One in particular. Patients may not be afraid of the doctor touching the computer keyboard to bring up their personal information, but many of them certainly are afraid of the docs touching certain personal body parts and telling them that something is wrong. To be specific, men are especially ticklish about another person putting their hands anywhere near their underwear-absent bottom. Computer digits are OK, but human digits to perform the routine prostate exam, aka the single-finger digital rectal exam — no thank you. As Shakespeare would say, “there’s the rub.”

A 2011 Esquire Magazine internet survey sheds some light on this dark place in doctor-land. The survey should not be interpreted as gospel, since it was taken by 519 internet-connected US males, a sampling technique that would tilt the results toward the young and relatively affluent, as well as more educated individuals than might be found in a more representative selection of the male population. That said, it does support the notion that males are touchy about being touched.

When men were asked which medical tests give them the most anxiety, two were tied for the top spot: the digital prostate exam and a colonoscopy, each chosen by 36% of the sample. By comparison, only 23% found a dental checkup to be the most upsetting, and just 5% admitted to being threatened by a hernia exam. Consistent with these results is the fact that only 30% reported having had the rectal (prostate) exam of those men between age 41 and 50 who participated in the research.

What might this suggest about the avoidance of doctors by some males? Conventional wisdom tells medical professionals that stereotypical men identify themselves as “tough” and don’t like appearing vulnerable. They are taught early some version of “the athlete’s creed:” if you are injured don’t complain, rub some dirt on the wound and get back into the game; don’t be a sissy, a wuss, a wimp, a pussy, a weakling, a girly-man or however else being “less than a man” might be characterized. By that standard, going to a doctor when you feel relatively fine is a sign of weakness or fear, a source of shame. And, indeed, there is data to suggest that lots of men do tend to delay seeing physicians even when they are sick; at least until some time passes and the distress can’t be ignored any longer.

The digital advances brought by computer technology (rather than the MD’s advancing digit) hold no such threat. Time will be saved by your doctor having immediate access to your medical history, a record that is not dependent upon your memory and that will be available on the desk top of all your physicians. Drug interactions will be more easily avoided and all the specialists should be able to smoothly coordinate your care as the team that they must be. Computers may even help in suggesting diagnoses that are consistent with your recorded symptom profile. Medical errors will be reduced. All the computerized data will also make medical research easier.

What medical apps won’t be able to do is get you to make an appointment with your doctor if you are afraid of either what he might do to you or what he might say about your condition. Many people would prefer to assume that if they feel good, doctors can be avoided. They like to think that the medical community is too much like any other business and that what passes for evaluation and treatment is just another way to make a buck. Trust is needed if you are going to put yourself in the doctor’s hands. Literally.

But what would make the digital rectal exam (or its even more invasive cousin, the colonoscopy, in which a tube is inserted into the colon through the rectum while you are under sedation) particularly scary? After all, the former takes just a few seconds, the doctor uses a lubricated glove to do it, and it isn’t painful. Well, probably a couple of things. First, men and women generally rate cancer as the disease that they fear the most. Since possible cancer detection is the usual reason for the routine digital rectal exam in men, it could be one of those things that men believe to be better left alone. In other words, don’t look for trouble and “if it ain’t broke, don’t fix it.”

But, there is more. And if you haven’t figured it out yet, it might just be an instinctive fear of assault from the rear. It is probably scary enough for many men to stand with their private parts exposed to another man, but likely even worse to be positioned with your back to him while he enters you. I’m not talking here only about homophobia, but equally about an instinct for self-preservation causing a kind of automatic terror of being injured. “Wild Bill” Hickok, the legendary gunfighter of the Old West, is a possible example of this kind of concern. Hickok is said to have always been careful to sit with his back to the wall. But on August 2, 1876 he joined a saloon card game where the only remaining seat placed his back toward the entrance. Twice he asked others to change seats but no one did. He was shot in the back of the head by a man entering from the door, just as he feared.

Lots of my male patients postponed or avoided the kinds of examinations that I’ve described here, even quite a number who knew very well that it was a good idea to get them. Some were ultimately persuaded by their wives to go to the doctor. Others might have been influenced if one appealed to the desire to be around long enough to care for their family. But, part of the dilemma is that men tend not to talk to potential persuaders about matters as private as this. And, if you don’t have a doctor (45% of the Esquire sample did not) he cannot advise you to do what is needed.

Clearly, early detection of serious medical problems represents a desperately important area for research into how to motivate terrified folks to do what is best for them. As much as we read about the advances expected from digital medicine, it might be useful to hear a bit more about what is being done to reduce the fear of medicine done with digits; a fear that remains in the shadows — an “unmanly” quality in some of the very same men who portray themselves as macho. If, as I’ve suggested, men avoid these tests out of age-old instincts for self-preservation, one can only be struck by the irony that their efforts at such self-defense increase the chance of an early and avoidable death.

As with all such sensitive and very personal areas of life, however, there is always room for a joke. My own physician told me the following:

I had a patient who came in for a routine digital rectal exam as a part of his annual physical. After that portion of the evaluation was completed, he asked me a question: “Doc, how many fingers did you use?” “One,” I answered. “Why didn’t you use two?” “Because the exam is done with just one finger,” I said. “Yeah, I know, but I wanted a second opinion!”

For a very funny, but also serious take on getting a colonoscopy, read Dave Barry’s A Journey Into My Colon — and Yours. The top image is called Index Finger by Cherubino, sourced from Wikimedia Commons.