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.)

"United States of Alzheimer's"

On May 16, Studs Terkel turned 95. He is precious. You may want to listen to his interview with Amy Goodman on Democracy Now!. The first time I taught Introduction of Political Economy at the University of Massachusetts, thanks to Steve Cohn's sound advice, I used interviews from his Working:What People do all Day and How They Feel About What They Do to illustrate and give concreteness to the various class structures (slave-labor, wage-labor, serf-labor, independent, and cooperative) within which working people participate.

A strong feeling of nostalgia towards the New Deal, to the Works Project Administration permeates the conversation. At some point, he speaks of the New Deal as an Utopian moment:

And then came the New Deal of Franklin D. Roosevelt and Henry Wallace, especially. And here came the jobs, the WPA of Harry Hopkins, Work Projects Administration. That meant work for men, for shovels -- also arts projects. There were artists and painters and dancers and singers. And this was all part of the New Deal.

In a sense, this reminded me once more that it is necessary to begin to understand what the New Deal means for the American Unconscious. Perhaps, it is the intimate alterity, the extimacy that haunts the hegemonic capitalism in the USA. The Social Security and its pay-as-you-go system is only one of the many institutional components of this American style "communism." Perhaps, it is the only one that is remaining. It was the institutional architecture (constructed by the nameless social engineers trained in the tradition of Dewey, Veblen, Commons style American pragmatism/institutionalism) of the New Deal and not necessarily post-war Keynesianism that which helped capitalism get out of the Great Depression and laid down the social technologies that enabled the petroleum-fueled post-war "Golden Age of Capitalism" (or, to borrow Tim Mitchell's terminology, carbon capitalist democracy). The extent to which these institutions are entrenched within the social formation can be gauged by the inability of the neoliberal counter-revolution to fully dislodge its key institution, the Social Security.

How does Social Security (in its pay-as-you-go version) count as a communist moment at the heart of this carbon capitalism? Simply because it enacts (as if it is a most reasonable and practical idea) the very communist axiom of "from those who can (the workers and the corporations) to those who need (the elderly, the disabled, etc.)". Without doubt, this is not a type of communism that I will be satisfied with. And, my aim is certainly not to perpetuate a new New Deal nostalgia. Yet, at the same time, when Studs Terkel complains about the social amnesia produced by the so-called "liberal" media and re-names the States as the United States of Alzheimer's (humorously modifying Gore Vidal's the United States of Amnesia), it is impossible to not to think of the strange and evasive way in which the American public relates to the New Deal.

Perhaps a half a decade ago, while cooking together with fellow blogger bigbadbull at our then Northampton ("Soviet Graves 1") residence, in the heat of the moment I claimed that Liberalism, as it is understood in the United States and perhaps best embodied in the public spirit of the New Deal, is the far most left position that one can feasibly take within the American political landscape. This is undoubtedly incorrect and the remaining portions of this posting will make it clear why it is so. Nevertheless, today, I would still insist on proposing the following modified hypothesis: The New Deal Liberalism constitutes the very frame of reference of a broadly defined American Left (and dialectically speaking the American Right). I would count the civil rights movement as an extension of the New Deal Liberalism. (So does, I think, Lars von Triers in his Manderlay, the second installment of his American trilogy). Even the radical left in the US (e.g., the new left of the Sixties), in its critique of the Soviet model, in its distance from Eurocommunism, and in its awkward relation to Maoism is the shape that the New Deal Liberalism took within the context of the Vietnam War.

In this sense, it would not be far fetched to argue that the New Deal Liberalism holds a place that is similar to the one Kemalism holds in Turkey. Not unlike the New Deal Liberalism, Kemalism determines (and truncates) the very horizon within which left operates within the broader social formation.

Nevertheless, of course, this hypothesis is bound to be proven wrong. There are social movements and political positions articulated within the past and the present of the US that breaks from and is opposed to the State-Capital-Nation knot (to use Karatani's metaphor-concept) of the United States of Alzheimer's even when its is tied together by the ideology of the New Deal Liberalism. Preceding the New Deal, there are the indigenous (or Indian and not Native American as Zizek would prefer to refer to them as, if only to demonstrate once more the stupidity of European settlers-colonialists) movements of resistance (which are themselves could be categorized as communist) against the settler colonization of the continent and, slightly later on, the Shakers who established their Yankee Communes on the basis of radical egalitarianism among genders and races—much before the North decided that it is in its benefit to do so. Again after the Civil War and before the New Deal, there are the Haymarket riots and the anarchists like Sacco and Vanzetti (don't miss the recently produced documentary) who articulated a different vision of solidarity and resistance against the onslaught of capitalism. And then, there is the Black Panther Movement moving beyond the Civil Rights Movement. And then...

Perhaps the others can insert their examples of left movements within the history and the present of the US that articulated/articulates a position beyond and against the State-Capital-Nation knot—even when this knot is articulated within the idiom of the benevolent New Deal Liberalism.