Health Care Reform Debate and Feminine Sexuation: Passage to the Act

(Dear reader, sorry for the delay in posting--this summer has been one long emotional roller coaster ride so far.)

Part 3 of “Health Care and the Community Economy: Towards an Ethics of Surplus and Geography of Sufficiency.”

Feminine Sexuation and Health Care Reform

So far we have learned what it is like to fail in relation to economic imperative—to fail to balance social reproduction and economic growth … My qualitative research alerted me that it is also possible to fail in relation to one’s ethical commitments.


One interview that stands out in this regard was with Dr. Norman Haug of Del Norte Colorado—driving force behind the creation of The Rio Grande Hospital. Del Norte is a remote town in South East Colorado with a mostly poor rural farming population and a seasonal tourism industry. Like a lot of poor rural communities access to health care was a real problem. Norman was able convince HUD to provide Del Norte with a loan type 242 that allowed for the construction of a critical care hospital to serve the local community. To obtain the grant he had to prove to HUD that the hospital was economically viable.

First Norman needed to raise a 1.5 million dollars in order to qualify for the loan—the first of its kind to be provided by HUD outside of the NY/NJ area. In addition to solicitations large and small the land for the hospital—valued at 400K--was also gifted by a land owner. To prove that the critical care hospital was viable one argument Norman made was that it would serve the tourists that came to the area for hunting and other excursions. The decisive point proved to be the hospitals designation as a critical care facility by Medicare.

This meant that Medicare—the insurance form for 70% of the patients—would reimburse the Rio Grande on a cost basis rather than according to capitated formularies—in the absence of this arrangement, the hospital would lose money. One of the rationales behind the critical care hospitals is that they provide care in sparsely populated areas that would otherwise fail to constitute a viable market.


This leads some to dismiss the Rio Grande as a state charity case but Norman disagrees on two counts: First, We would not argue for the centralization of police or educational services on the basis of market demand… nor should we argue for a centralization of medical services. Second, once transport and higher overhead in urban hospitals are figured into the equation—critical care facilities and rural hospitals are cost effective responses to definite need.

Situating the Rio Grande in the Diverse Economy

It is useful to situate the story of the Rio Grande hospital in the context of the diverse and community economy diagram, with its partial typology of economic difference in the dimensions of exchange, compensation and organization. For those of you familiar with A Post-Capitalist Politics, it will be unnecessary to go over the way in which this representation of the economy as a space of open-ended heterogeneity describes an actually existing diversity of forms of exchange, compensation, and economic organization (the dimension of class). The Rio-Grande is a state capitalist enterprise that exists to serve a particular constituency. While it has clearly been enabled by a generous state transfer from HUD and its designation as a critical care facility by Medicare, it’s also clear that it exists as a community asset because of the generosity of local citizens. In turn, it is a context in which Norman and the other physicians are able to generously serve the care needs of the local and transient population—including legal and illegal immigrants. (45% of care is free care) and the market of insured patients.

Thus the Rio Grande is “viable” because of the support that it receives and because its mandated purpose is to service a geographically finite need. There is, of course, a limit to Rio Grande’s capacity but it no longer needs to be read in relation to infinite demand and self-interested practitioners.

Lacan’s counter-posed feminine logic becomes relevant here. In this view there is no constitutive exception—all are subject to the law, and yet no one is completely subjected. In the world of feminine sexuated logic limits remain, including limits to care, but they are seen as provisional. Here “scarcity,” and the need for “economic growth,” no longer act as over-arching imperative. In my view, it is this move towards the relational possibilities (and constraints) of a feminine logic rather than the fixed miserly injunction of masculine logic that allows us to re-imagine the politics of health care reform in relation to sufficiency.

Feminine logic, as Copjec says, “obliges us to recognize the finitude of all phenomena, the fact that they are inescapably subject to the conditions of time and space and must therefore be encountered one by one, indefinitely, without the possibility of reaching an end, a point where all phenomena would be known. The status of the world is not infinite but indeterminate.”

Health care reform will continue to fail us, but we will fail to arrange and allocate care in relation to an ethical imperative rather than a miserly economistic imperative. We need a language of partial subjection in order to produce a politics of ethical possibility. A sufficient response to definite need is something that is intelligible in the spatio-temporality of needs encountered “one at a time.” Likewise, the range of existing assets, and the generosity of the community—and here I include the state as simply a part of community—needs to be encountered in their particularity also. While this indeterminate mobilization of social surplus, generosity and ethical commitment is what allows for the Rio Grande to succeed—the success of community health centers elsewhere would depend on the identification of definite resources (and constraints) that occur in any given area.

Fifty years ago people took the risk and they built these hospitals, we need to do it again. And we just need to get it done… Get the hospital built and let the person whose going to be here ten years from now worry about it. I mean that sounds callous but that’s what it amounts to. (Norman 2005)

Derrida taught us that an act can only be considered ethical when the outcome of the act is uncertain. What is clear from his statement here is that Norman truly is not clear what the outcome of his efforts will be but he is willing to act anyways. Perhaps Norman’s status as an ethical agent—his willingness to take the risk in order to “get it done”—allows us to see the typical mainstream approach to health care reform, as mired in a masculine sexuated logic of impossibility, as an imaginary solution whose elegance and inevitable failure leaves things exactly as they are. The imagined social harmony between the conservation of capital and the equitable allocation of care is never arrived at and this failure is symptomatic of a castrating approach to health care reform.

In contrast, Norman’s capacity to meet the needs of the immediate community, his adoption of the standard of a sufficient response in relation to definite pressing needs, is sustained not by the idea of a final/fantastic end point but a spirit akin to what Zizek describes as “enthusiastic resignation.” Through Norman we can come to see the difference between the failure to embody (the reconciliation of equitable health care allocation and continued economic growth) versus a failure in relation one’s ethical principles (to care and accept whatever comes as a result of this commitment).

How is that Norman came across this affective disposition, this willingness to pass to the act?

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

Part 2 of “Health 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.)