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Sunday, May 20, 2007

Health Care Reform Debate as Castration: Masculine Sexuation and Health Care Reform

Part 2 ofHealth Care and the Community Economy: Towards an Ethics of Surplus and Geography of Sufficiency.

The U.S. Health care reform debate centers on the question of whether care is a right or a commodity. Do markets exclude people from access to care or does competitive pressure work to make care progressively more affordable? Could the state guarantee access to quality care for all or would a national health insurance system mean equity of misery? With stunning regularity this debate between universal health care advocates and pro-market reformers has been restaged without being resolved. It is precisely this repetitiveness that has led me to regard the health care reform debate as a social fantasy whose aim is the conservation of the subject—the maintenance of an identity that is both formed and trapped by the impasse of this debate. How does this work?

Advocates of free market reform and those who champion a right to care share a common understanding of patients and providers—as rational, utility maximizing subjects through the economistic theories of moral hazard and demand inducement—patients are infinitely needy and providers are infinitely greedy. It is this a-priori conception of the subjects of care that installs an economy of scarcity as the master signifier in health care reform discourse. It is no surprise then, that private HMOs, Medicare and Medicaid bureaucrats have simultaneously developed similar approaches to constraining patient demands and controlling costs, regulating the enjoyment of patients and providers.

My argument here is that both sides of this debate speak a language of optimized care delivery—frequently drawing upon the industrial language of total quality management—when discussing the efficacy of captitated Medicaid payments in Utah, tort reform in New York, or automated record keeping nationally. It should be kept in mind, however, that these practices of miserliness produce the scarcity they presume. What happens to us when we accept this description of patient and provider motivation?

When we accept the premises of this debate—how subjects are conceived—we enter into a symbolic order that constrains enjoyment in a particular way. If both Medicare bureaucrats and HMOs use capitation and co-payments to control costs, they are directed to do so because this debate regards reproductive labor as a social cost that must be minimized in order to conserve capital for economic growth in productive sectors. We can enjoy some “social reproduction” only so long as capitalism’s access to capital remains unconstrained and unquestioned.

[I should note in passing that the policy directed bureaucratic form of this debate has its equivalence in the popular imagination: the search to find some extraneous enjoyment, some excessive demand whose curtailment—it is believed—will restore the balance. The anti-immigrant group the Minute Man has publicly stated that illegal immigrant demand for health care is an onerous and unnecessary burden placed upon the health care system that is responsible for rising health care costs. Indeed, if one were to visit hospitals in border regions one would find confirmation of this belief. However we must bear in mind Lacan’s scandalous proposition that a husband’s jealousy is still pathological even if his wife really is cheating on him. What we need to question here is not the empirical assertion that some portion of aggregate demand for emergency health care arises in the immigrant population (legal or otherwise) but rather the belief that eliminating this demand will be sufficient to fix the problem.]

Following Özselçuk and Madra's indispensible "Psychoanalysis and Marxism" we can recognize that it is the singular exceptional status of productive capital and the subordination of the sphere of social reproduction that allows us to recognize that health care reform is carried out in relation to a masculine or dynamic logic.

“There is at least one X that is not subject to the phallic function.”
Productive capital’s access to the surplus is unconstrained because all other claims (for social welfare) are subject to castration. It is the exception that allows the rest to be subject to the law of scarcity.

“All Xs are submitted to the phallic function.”
For Lacan, as for Kant, these cosmological propositions show a limit to the law language enunciates. In masculine sexuated discourse the failure takes the form of a contradiction that is ignored. The subject emerges at this point of failure

Preferred provider networks were seen as an effective strategy to control costs until the late 1990s when patient dissatisfaction led to legislation (patients bill’s of rights) that undermined their efficacy. PPNs were a stand in for a social order, a reconciliation of contradictory demands—that failed-us. The failure of masculine logic is a failure to embody. Preferred Provider Networks failed and Medical Savings Accounts (the new solution) will fail as bureaucratic responses to the perceived economic reality of scarcity—a reality which demands that we be happy with our castration. This partially explains Uwe Reinhardt’s (see left) observation that “we will always have health care reform, and it will always fail.”

Thus, as Joan Copjec the tenents of masculine sexuation are not antinomic propositions as they appear but are simply statements that exist in a state of simple contradiction that is disavowed. It is precisely this disavowal that allows for practitioners of believe, in all sincerity, that they have arrived at the solution this time only to have it fail.

(To be continued in Part 3.)

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