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.

What I Have Learned So Far: Life Lessons, Part I

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Long ago my maternal grandfather told me he missed the boat on his 1912 journey to the USA, trying to sail from England to America. He was late for the Titanic. My mom heard this in her own childhood, decades before movies like Titanic made such stories more common.

Grandpa was a warm, dashing, multilingual man; originally from Romania: the loving and lovable grandfather of one’s dreams. Leo Fabian was easy to look up to; and not only because he was over 6′ tall, slender, straight-backed, and imposing in an era of men of more modest presence. Grandpa owned a wonderful, rascally smile and enough charm to enchant a small village, a bit like Harold Hill in The Music Man. He was the life of the party.

Soon enough I learned that alcohol had been a nemesis never defeated, ruining him in the eyes of his son and much of the world. By the time I was a teen I saw my grandfather hungover, chagrined, and shrunken. My last memory of him is when he offered a weakened, but still welcoming smile for me, his oldest grandchild, from his hospital bed.

Of course, he was a story-teller. No surprise, the Titanic tale was unverifiable.

I think my informal education began with observations of Grandpa, who unintentionally provided me with lessons he never intended to teach. I learned that people with admirable qualities, even those full of love and humanity, can be grievously flawed. Moreover, I realized you can’t believe everything you are told, no matter how much you admire the teller. These were necessary lessons, cruel lessons.

We are carried through life in a flood of such instructions, some needful of learning, some wrong; some unlearned, never learned, or learned badly. All of us are lifelong students enrolled in the school of experiences, a university whose classes are taught in the midst of a vast river: now calmly flowing, now surging. Drop out and avoid experiences at your peril: little learning is found below deck, where the beautiful, sunny, glorious days on the water will also be missed. No perfect grades, either, even for those of us who man the sails and survive the episodes of seasickness.

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Since I’ve been on the voyage for a while I thought it might be useful to pass along some ideas not expressly taught, not usually written, and not often offered as sage advice. This is not exhaustive and not everything you will read here can be proven. Still, I began this blog with the idea of presenting ideas about life for my children and I now have a grandson who might profit from them (or run screaming into the night believing elders are best ignored). Here, then, for whatever value you assign, are off-beat bits of what I think I know:

  • I have met no one I thought to be completely evil, evil 24/7. We’d have an easier time identifying them if they were. Indeed, some of the least trustworthy folks were quite charming and generous. The world is full of gray tones. Still, dark gray is to be avoided.
  • Life lessons are often age-dependent. The lessons of youth apply to that time, the lessons of age to another time. Just as the customs of one country differ from another and must be used in the right place and moment, one should acquire the knowledge applicable to the period of life in which you live and use it in a timely way. Perhaps our learning ought to come with a “use by” date. Beware of employing old, once effective strategies which now fail with some regularity. We cannot “freeze dry” our lives. We must continue to adapt.
  • “Some people are so busy learning the tricks of the trade that they never learn the trade.” So said Vernon Law, the best pitcher in baseball in 1960 and a member of the World Series Champion 1960 Pittsburgh Pirates.
  • Fame, that is to say “celebrity,” is fleeting. Ask Vernon Law, still alive at 86. I’ll bet you don’t know his name unless you were a baseball fan 50 years ago or live in Pittsburgh. Nonetheless, I’d have loved to spend one day in Willie Mays’s skin in his prime, a contemporary of Mr. Law. I’m sure I’d immediately have become addicted to the excitement and adulation.

13 Oct 1960, Pittsburgh, Pennsylvania, USA --- 10/13/1960-Pittsburgh, PA: Photo shows the seventh game of the World Series between the New York Yankees and the Pittsburgh Pirates. Vernon Law, Pittsburgh Pirates pitcher, is shown in mid-pitch action. --- Image by © Bettmann/CORBIS

  • “It is what you read when you don’t have to that determines what you will be when you can’t help it.” And just think, Oscar Wilde wrote this before Kim Kardashian was born.
  • If you believe everybody should be able to reason his way out of a paper bag, remember that half of the population has an IQ score below 100.
  • “If you want revenge, be sure to dig two graves.” An old Italian expression about the cost of undiminished anger.
  • The older you get the more time you spend on maintenance. Your body requests nothing when young, quietly obeying your every command, but recording your debt to it. The bill comes due later. By 29 I had to stretch before softball games. As I approached the age at which my dad had a heart attack (47) I began regular aerobic exercise to stay in shape. Stretching by now was a time-consuming daily event. Doctor visits, instances of physical rehabilitation, and occasional surgery enter the picture for many of us, jamming up the schedule. All of this happens gradually, little things accumulate. The change is both astonishing (because you didn’t think it would happen to you) and unremarkable (because you adjust to most of the nicks, scratches, and dents). Things wear out, something you knew abstractly, but hadn’t yet lived. Then you begin to have regular conversations with your friends frontloaded with physical concerns. You hear yourself making comments like this:

“The funniest thing happened yesterday, Steve. I was relaxing in front of the TV and — in the middle of everything — my nose fell off. Lucky for me, I caught it on the way down. A little glue and it looks like new, right?”

Of course, what is Steve going to say? That is, if he is able to speak. I wish I could pinpoint the exact date I turned into this person — like, perhaps, Tuesday, March 8 — but I can’t.

  • Even so, you will still think of yourself as about 20% younger than your real age (assuming you are over 40), perhaps explaining the frequent mismatch between the way people dress or wear their hair and what might be considered “age-appropriate.”
  • We are poor at affective forecasting: predicting our future feelings. An example: “When I make $10,000 more I’ll be happy.” Ask those who have won the lottery for the answer.
  • We are also bad at affective forecasting when it comes to negative events. Given enough time we tend to get over things. However, you might not want to wait months or years. The profession of psychotherapy depends on this, in part. There are also countless exceptions when no amount of waiting will lift you to a higher altitude. Psychotherapy is available for this, as well.
  • Some people, almost always men, succeed in life because they are like blunt objects with eyes, who see a door and keep banging on it until the door finally collapses. A number of women marry such a man thinking he will protect them. They admire his persistence or give in to his unrelenting will, though they aren’t emotionally drawn to him. You will also notice many of his kind on the political stage.

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  • Look around you. If you think we humans are rational at all times you haven’t been paying attention. By the way, you are human, therefore …
  • On the other hand, if we were absolutely rational we would be machines: I’d rather have love, even at the cost of heartbreak; joy, even at the cost of disappointment; pleasure at the cost of pain.
  • Time will change you or at least it should. More even than learning from experience, the body and brain do their own shape-shifting and gradually alter who you are. Some of what passes for wisdom is simply getting older, inhabiting a different physique with an altered mix of chemicals running around.
  • No matter how intelligent or physically attractive you are, a number of people won’t want to spend time with you. You will likely believe this is your fault. “Maybe I’m not funny enough, smart enough, well-proportioned enough,” you think to yourself. More often than you imagine, however, it is just because you part your hair the way their father did, a factor of which even they are unaware. Transference is everywhere, not only in the therapist’s office.
  • We all need some amount of compartmentalization and denial. Otherwise life is simply too much. Within limits, the ability to lose yourself in an activity as simple as reading a book or having fun at a party is a great gift. Self-consciousness, being preoccupied with your thoughts about yourself, demands an escape.
  • Sunny days can turn cloudy. I learned to look back and figure out when exactly my mood changed and thus determine what bummed me out. Unravel your discontent early enough in the day and you will sleep better.
  • If you provide friends with too much truth about themselves you are in danger of losing them. Provide them with too little, however, and they aren’t worth having and you aren’t being a good friend.
  • I discovered the generation gap around age 26. Lecturing at Rutgers University I mentioned Adlai Stevenson II. The statesman had died only about eight years before. Stevenson was twice the Democratic Party’s nominee for President and remained a prominent international figure at the time of his death. No one in the large lecture hall of undergraduates knew who he was. These days I find myself spending more time explaining what I’m talking about when I refer to the past.
  • A Bulgarian patient once said, “In the United States people live to work. In Bulgaria we work to live.”
  • I’m still learning. A Thursday night PBS interview of Vice President Joe Biden offered the following anecdote. Judy Woodruff asked him about his plans after leaving public service. Biden referred to issues about which he was still passionate and for which he intended to continue his work:

My dad had an expression: ‘A lucky person (is someone who) gets up in the morning, puts both feet on the floor, knows what he is about to do, and thinks it still matters.’

Biden remains, despite enormous life losses and setbacks, a happy man. By his father’s standard, he is lucky, indeed.

The top photo is The Steerage by Alfred Stieglitz. Taken in 1907, it is among the most famous photographs in history. The lowest class accommodation was literally the lowest on the ship and those who were “upper class” did, literally, look down on you. My grandfather likely took his voyage on such a ship, but I have no idea where he was situated on the boat. The second image is called Life Buoy, the work of Shirley. Both were sourced from Wikimedia Commons.

 

“Relationship Crime” or the Man Who Knew a Little Bit Too Much

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Knowledge can be a problem. You know the old saying, “A little knowledge is a dangerous thing.”

I once had a friend who was dating a lovely woman. She was charming, sweet, and fun to be with. And, this lady was very kind, a person who respected others and went out of her way not to do harm. My wife and I enjoyed her company and my friend seemed to appreciate her immensely, as well.

But, not really looking for someone else, he stumbled upon another woman who pursued him; a pursuit to which he succumbed. Rather quickly, it is true. He didn’t put up much of a fight.

She too was charming and perhaps a bit more energetic than his current lover, and I suspect a little bit sexier, too. She had a sleek sultriness that his girlfriend didn’t possess. But since he never told woman #2 that he was “involved” with someone else, he was “fair game” as far as she could see; and he certainly didn’t proclaim any abiding allegiance or committment to the lady he’d been dating.

From this point, my buddy enjoyed the company of both women — enjoyed sex with each of them — and he saw no reason to tell either one about the other.

But he did tell me what he was doing.

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I asked if either one knew that he was sleeping with someone else; and he had to admit that each of them thought she was in an exclusive relationship with him — that she was the “one and only.”

I pointed out that there was implicit deceit involved, since he knew that his lovers were with him only because they did not know the truth.

“No one is being hurt,” was his reply. And he was sure, he said pre-emptively, that he did not have a sexually transmitted disease, which he’d checked out recently with his MD. No one was in harm’s way from physical disease, he assured me.

As far as this man was concerned, he had made no promise of eternal fidelity and believed that a “no strings attached” understanding existed all around.

My friend was not a young man, nor were the two women — the three of them hip-deep into their fifth decade on the planet. Everyone had been around the block several times. All parties had been hurt more than once. They knew the pain of heartbreak. They didn’t need any more of it, not that anyone of whatever age needs more. It was just that the resilience of youth was no longer as available to any of them as it had been a while back, and one would have hoped that the man had thought just a bit about this fact.

I asked him how he would feel if his youngest sister were sleeping with someone who was doing what he was doing: simultaneously having sex with another woman whose existence was a secret?

This sort of thing used to be called “two-timing,” but I didn’t remind him of that.

He pretended that he did not hear me. Better to keep the walls up, the compartments separated. It was the sort of response (or lack of response) you get from someone who doesn’t want to think any troublesome thoughts that might arouse his slumbering conscience. And so he kept the metaphorical blinders on himself, so that he could not see the collateral damage of his self-serving behavior.

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Although he wouldn’t have admitted it, he viewed these women “instrumentally” — in terms of what they were good for and how they could be used, while comforting himself that “no one is being hurt.”

Perhaps you are asking why all this troubled me. Several reasons. I cared about the first woman — my wife and I both cared about her — and were happy to have become her friends. We knew that she was being fooled, even if she was not presently in any pain. We knew that the “relationship” was based on deceit and her lack of knowledge. We expected her heart to be broken before long. And, I felt bad about the moral degradation of my friend, someone who I could no longer look at in the same way as before — could no longer respect as I once had.

My buddy told me all that I have now related to you on the condition of confidentiality. But that was going to be a problem. Not that I would break his trust, but that I now had what might be called “guilty knowledge.” I knew too much for my own good.

My wife and I had a double-date scheduled with our friend and girlfriend #1. At dinner I was uncomfortable. I knew something that his lady friend didn’t know and I realized that eventually she would be left spinning, which didn’t lighten my mood. It was as if I had just read her X-ray and discovered a spot on her lung about which she knew nothing — yet.

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Nor did I want to participate in the sham of their implicitly exclusive relationship, the references to future things that they planned on doing (some with us), or watch the way that this gracious and good woman-in-love looked at a man who, although he was my friend, was ( I now realized) not nearly so gracious and good; and not in love with her.

The day after this get-together, I phoned to tell him that so long as he was dating both of these women I could not go out with him in the company of either of them; I could not pretend that I didn’t know what I did know.

I knew a little bit too much.

It was not long before my friend ended the contact with the first woman. I suspect that his decision to end the relationship had more to do with his developing feelings for female #2, than any unhappiness with his first girlfriend or the flowering of his dormant conscience. And, I’m pretty sure he’d had difficulty coping with the logistical problems of juggling two relationships, each with a woman who wanted as much of his time as he could give. After all, there are only seven days in a week and the task of keeping both women happy (and unaware of the other) began to wear him down a bit.

And just to show how little influence I had on my friend, he repeated the two-timing when another woman came along who found him attractive. Now girlfriend #2 achieved the position of the previous girlfriend #1, and like here predecessor, she too was eventually taken to the relationship consignment shop. I guess practice makes perfect.

Many years before, when I was an intern in a psychiatric hospital, I recall a raving, out-of-control man being brought into the locked-unit to which I’d been assigned. He was suffering from Bi-Polar Disorder, which you might know by the label Manic Depressive Disorder. Clearly, he was in a manic phase — grandiose, impulsive, erratic, exploding with energy, and incapable of making good judgments.

He had been a high school teacher of mine. A wonderful teacher. Fortunately, he didn’t seem to remember me and I made no effort to remind him of who I was and thus risk embarrassing him.

There are things that we don’t want to see in life: the failings of our friends, the frailty of respected parents and teachers, the needless hurt that one person we care about is doing to another one we care about. We don’t usually want to be party to deception, an accessory to even the kind of commonplace “relationship crime” that my friend was committing against a woman he liked very much.

None of this is very earth-shaking, I know. Unless, of course, you are girlfriend #1. But watching people diminish themselves is no fun, even for therapists who see it every working day. Bad decisions, hurtful decisions, thoughtless and self-serving decisions — all of it part of routine human experience.

We’ve all done some of it, but the best among us learn that it is wrong while others just keep on doing it.

As I said at the start, “I once had a friend…” He might now more accurately be described as an acquaintance. Someone about whom I think wistfully, remembering the days when I thought he was better than he turned out to be. Was he? Had I simply missed some things about him, never seen him in the kind of situation that revealed his limitations?

Sometimes the only conclusion to the story is “I don’t know.”

The top image is Two Women with Sink by Ernst Ludwig Kirchner. The second photo is of Bernard Spindel Whispering in the Ear of James R. Hoffa in 1957, taken by Roger Higgins, a photographer for the New York World Telegram and the Sun newspapers. The following picture of a Saddlebred Stallion in Harness is the work of Steve Fortescue. Finally, the flash-animation Spinning Dancer was created by Nobuyuki Kayahura at the Procreo Flash Design Laboratory. All images are sourced from Wikimedia Commons.