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.

Denial, BP, and You

Denial isn’t a river in Egypt. It apparently is, however, related to a river of oil in the deep water of the Gulf of Mexico

But there is more to denial than British Petroleum’s failure to consider the possibility that a disaster might happen.

No. Denial is something we all do, at least some of the time.

Still, let us start with BP. Major environmental accidents involving oil have not caused this company and others like it to spend significant money on safety considerations and the prevention of ecological calamity. Clean-up technology remains much the same as it was 40 years ago.

What were the oil executives thinking? Perhaps, that such things wouldn’t happen to them or on their watch. And if it wasn’t going to happen, why reduce profits to take “unnecessary” safety measures. This, despite repeated oil spills over the years.

An example, might illustrate how “denial” such as this is possible, starting at a tender age.

Back when I was a very little boy, I did something similar. I remember walking to Jamieson School on a very foggy day. Indeed, the fog was so thick that one couldn’t see more than perhaps a half-block ahead. Somehow I got it into my head that if I couldn’t see my school, perhaps it no longer existed!

Jamieson School, an enormous building, occupied most of a square city block on Chicago’s North Side.

But maybe, just maybe, it had disappeared!

I didn’t think about the details of how such a thing might have happened overnight. I didn’t imagine what effort it would have taken to disassemble the structure brick-by-brick or consider that I would have heard any explosion that razed it. No, for me, the disappearance of the building would have been a result of magic. Here one minute, gone the next.

Unfortunately, or so I thought, it finally came into view. And with it, another day of school; not the day of fun I had fantasized about on my journey from home. I couldn’t have been more than six or seven at the time.

The point being, that if grown men act like seven-year-olds, we have a problem. And problem is called denial — a failure to reckon with reality — at least at the extreme.

I’m sure you can think of lots of examples. The cigarette-smoker who never thinks about heart disease, emphysema, or lung cancer happening to him; the person texting and driving, who can’t imagine the possibility of an auto accident; the 350 pound man who has two-quarter pounders with cheese, fries, and a diet-cola, and somehow persuades himself that he is being careful about what he is eating because his meal includes a low-calorie soft drink.

More examples: the man who fancies a partner with a history of infidelity, but doesn’t grasp that he could be victim to the same fate as his predecessors in dating her; the morally upright and self-righteous citizen who cheats on his taxes; the parent who persuades himself that his lack of time for his children will be no problem for them; or the family that normalizes and minimizes the drinking of the household’s head, rather than facing his alcoholism.

Not to mention the biggest denial of all — that we are all mortal, all going to die, and that it could happen at any time — not just to the other guy, but to me! Instead, we treat it as unusual and remarkable when someone expires before, say, 70, when it is actually a fairly commonplace event (however, sad it might be). Indeed, I’ve known more than one therapist who avoided thinking about the topic. See Ernest Becker’s Pulitzer Prize winning book The Denial of Death for more on this subject.

In fact, it is our mortality, the very jeopardy of living and the tenuousness of life, that makes denial necessary and healthy for us to do some of the time, even if a number of folks use it altogether too often. Without some amount of denial (coupled with a little courage) it would be hard to get up in the morning and walk out of the house, fearful as we would be of accident or injury on the streets or highways. How could my parents have permitted me to walk to Jamieson School as a little boy unless they put aside the possibility that I might be abducted or harmed? Would you be able to fly to New York City unless you “strapped-on” intellectual blinders to the danger of your plane crashing or another terrorist attack?

At another level, denial simplifies our lives, removing potentially uncomfortable inconsistencies between who we are and who we think we are. It allows us to engage in life and take action without the burden of too much troublesome data that might interfere with pursuing often necessary self-interest.

As I hope you can see, we need some amount of denial just to get through the day. So, while you rage against BP (and they certainly have earned your enmity), do realize that they were simply doing something we all do frequently, but they were using that psychological defense on a much more grand and dangerous scale than most anyone else.

The truth is, no one can look life squarely in the face all the time, lest he be perpetually distressed by his vulnerability to misfortune on the one hand, and an overbearing conscience on the other. Denial is almost as necessary as the air we breathe and the water we drink. Of course, if we deny the dangers of pollution as did BP, we just might foul up that needed air and water, quite literally.

Life is complicated, isn’t it?

The image above is of the author, at a time before he had any thoughts about disappearing schools.

Is There Such a Thing as Bad Luck?

https://i2.wp.com/upload.wikimedia.org/wikipedia/commons/thumb/a/a5/6sided_dice.jpg/240px-6sided_dice.jpg

I once met a man called “Lucky.” My garage door had failed and he was the repair man. I saw the name on his jacket and asked him about it. He said that until about 10 years before, everything had worked out just right in his life, hence the nickname. But then the wheel of fortune turned and illness and death followed, including the death of his wife. “Lucky’s” luck had run out.

Shakespeare had a sense of such things. Thus, in Hamlet, following the deaths of Polonius and Ophelia, we read the words, “…When sorrows come, they come not single spies, but in battalions.” More colloquial usage tells us that bad events come “in threes.” Same idea.

The other side of bad luck, is the good. Branch Rickey, the baseball executive, famously said,  “Luck is the residue of design.” Of course, he was talking about good luck and how careful planning and persistence helped create it, or made it look as if it had been created. And a woman of my acquaintance, someone who lost a parent early and a husband late, has only recently met the love of her life. Better to have good luck late than early, it would seem.

Still, if one reads Greek mythology, one finds Solon, a wise man, counseling that no one should consider himself (or be considered) happy, until the last possible moment of his life, because misfortune yet has time to occur. “Lucky” would agree.

Some believe that there is no such thing as luck: that you get what you deserve and you deserve what you get, a Karmic view of things. Churches of prosperity promote “right thinking and right living” in the belief that you will be rewarded in this life and the next for such action and the correct form of religious observance. And if we read the Book of Job, in the Hebrew Bible (the Old Testament) we find a man who has all manner of bad fortune thanks to a friendly wager between the angel Lucifer and God.

Job had been a prosperous, religious, happy, and good man. But he is made to suffer all sorts of loss and pain so that his devotion to God might be tested. Three friends come to ask him what he could have done to deserve such misfortune. Surely, they tell him, he must have done something iniquitous. Clearly, they don’t believe in the notion of “bad luck.”

Many years ago a social psychologist name Melvin Lerner proposed something called “the Just World Hypothesis.” Lerner contended that when we observe misfortune occurring to another person, we prefer to believe that the individual has done something to deserve the negative events befalling him. But, if it is clear that he did nothing, then we will tend to devalue him personally, in effect saying, “well, maybe he didn’t do anything to cause his problems directly, but he isn’t a good guy, so, in a way, he deserves what has happened anyway.”

Lerner maintained that people do this sort of mental gymnastics unconsciously in order to fend off the notion that something bad might happen to them. “Terror Management Theory” has picked up where Lerner left off, looking at how we manage and try to mute the anxiety caused by our mortal state.

You say you don’t believe in luck? Well then, you must believe that all disease and all accidents “happen for a reason,” that the explosion of a volcano, for example, is guided by some divine hand. But when those illnesses, accidents, and misfortunes target the innocent, especially little children who are raped or tortured, you will be hard pressed to find a reason that is adequate. “Ah,” some say, “we, on earth, don’t understand God’s ways; but surely, this will be for the best in the end.” The conversation is never ending, and it is unlikely that either side will persuade the other.

Finally, there is the question of how to define when a thing is good luck or bad. According to another Greek myth, Cleobis and Biton were the two sons of Cydippe, who needed to attend a religious festival at some distance from her home. However, oxen to draw her cart were not available, and so these two good young men yoked themselves to the cart and got mom to the festival on time.

Their act of devotion to their mother won wide praise, but since they were exhausted, they soon needed to nap. Cydippe, who also had been praised for having raised such offspring, prayed that her sons would receive the best that any man could obtain. And, ironically, this wish was granted in the form of the their painless deaths as they slept, dying after having received great accolades at the pinnacle of their lives; now they would not have to suffer whatever else might come as they aged.

Good luck? You be the judge.

The photo of four colored dice above is the work of Diacritica, sourced from Wikimedia Commons.

A Few Good Books

You won’t be looking at this unless you are a reader. So here are a few brief recommendations of books that have made a lasting impression on me. Most are not new and I suspect that some are out of print, but are likely to be obtainable by a search on the Internet. In no particular order:

1. Frauen by Allison Owings. Owings comes as close as anyone to answering the question, “How did the Holocaust Happen.” An American journalist who studied in Germany, she returned there to interview mostly gentile women who had lived through the period of the Third Reich. Owings summary does an extraordinary job of describing the psychology of the bystanding German population.

2.  A Prayer for Owen Meany by John Irving. Irving gives away the plot of his novel early on: Owen Meany will die an unusual death. But rather than destroying the tension of the book, this puts the reader in Owen’s shoes as a man who knows that he will come to an untimely end, but doesn’t know exactly how. As the book progresses and that end comes closer, the terror is almost unbearable.

3.  Agitato by Jerome Toobin. The story of Toscanini’s NBC Symphony Orchestra in the one decade that it attempted to survive after his retirement. If you enjoy anecdotes about famous musicians, this book is for you. The tale Toobin tells is both funny and sad, since the orchestra did not last. Jerome Toobin, by the way, is the father of Jeffrey Toobin, the legal scholar and public intellectual.

4.  Regret: the Persistence of the Possible by Janet Landman. A book about the title emotion, viewed from literary, psychological, and other perspectives.

5.  What is the Good Life? by Luc Ferry. A very good attempt to answer the biggest question of all: what is the meaning of life?

6.  The Long Walk by Slavomir Ramicz. The author tells the true story of his escape from a Siberian prison camp. He and his compatriots, with almost no equipment, food, or appropriate clothing, attempted to walk to freedom and Western Civilization, which took them as far as India. As you can imagine, not all of them made it. That anyone at all did is astonishing.

7.  Anna Karenina by Leo Tolstoy. This story of an unhappily married Russian woman touches on almost all that is important in life: love, friendship, obligation, children, religion, the value (or lack) of value to be found in work and education, death, and the meaning of life. None of that would matter much without the author’s gift of telling his story and allowing these issues to flow out of the human relationships and events he describes.

8.  The Boys of  Summer by Roger Kahn. Kahn’s classic tribute to the Brooklyn Dodgers baseball team of the 1950s, the team that had Jackie Robinson as its central figure and leader.

9.  War Without Mercy by John Dower. Dower describes the racism that underpinned the Pacific theater of World War II. Unlike the war in Europe, each side viewed the other as less than human and treated the enemy with a brutality consistent with that view.

10.  The Culture of Narcissism by Christopher Lasch. Although the book is now a few decades old, the writer’s message is still spot on. He looks at the empty pursuit of happiness in material things and acquisitions, driven by the increasingly disconnected nature of social relationships in this country, and the promise of the media that happiness lies, not in fulfilling human contact, but in the goods that come with “success.”

11.  The Time Traveler’s Wife by Audrey Niffenegger. A fantastic and touching creation about a man unstuck in time, thrown forward and back, and the woman who loves him. Its being made into a movie, I’m told.

12. Patrimony by Philip Roth. Roth’s account of the illness and death of his father.

13.  The Denial of Death by Ernest Becker . More than one person has told me that this is the finest nonfiction book they have ever read. It is a meditation on what it means to be mortal, and how the knowledge we all have of our inevitable demise influences how we live, in both conscious and unconscious ways. Becker’s book has lead to an entire area of psychological research called “Terror Management Theory.”

14.  For Your Own Good by Alice Miller. Miller is a controversial Swiss psychiatrist who looks at the effect of harsh upbringing on the welfare of children. If you believe that children should be seen and not heard, this book might make you think twice.

15.  A Tale of Two Cities by Charles Dickens. A story of self sacrifice and heroism set in the French Revolution. If you can read the last few pages without tears, you have a firmer grip on your emotions that I have on mine.

16.  The Glory of Their Times by Lawrence Ritter. Ritter was a college professor when he began to travel around the country in the 1960s, tape recorder in tow, to obtain the first hand stories of the great baseball players of the first two decades of the 20th century, who were by then very old men. Probably as great an oral history as any of those written by Studs Terkel, and perhaps the greatest baseball book ever.

17.  American Prometheus: the Triumph and Tragedy of J. Robert Oppenheimer by Kai Bird and Martin Sherwin. Oppenheimer is the man who brought the Manhattan Project to fruition, that is, helped create the bomb we used to end World War II in 1945. But more than that, this book is a wonderful biography of a complex, peculiar, and brilliant man, who was brought low by those who wished to discredit his opposition to nuclear proliferation in the period after the war.

18.  The Mascot by Mark Kurzem. A story that is beyond belief, but turns out to be true. The central figure of the story, when he was a little boy, was adopted as a mascot by a Latvian SS troop after surviving the murder of his family. Why beyond belief? Because he was Jewish. The book reads like the most extraordinary mystery.

19.  All Quiet on the Western Front by Erich Maria Remarque. The most famous anti-war novel ever written. The book is told from the standpoint of a young German infantryman during World War I.