The American Way of Illness

Though President Obama has refused to seek to make health care in the United States universally available — a bone of contention in his campaign against Hillary Clinton last year — he has vowed to bring it closer to universality. As one whose health insurance (American) is flimsy at best, I like the idea of affordable, available health care. I’m baffled by those Americans who treat health as a kind of commodity, upon which prices can be put, and which should be bought and sold like pork bellies in a free market. I’ve never quite understood why a doctor who charges more is automatically accepted as better qualified, or why a drug that costs more is more effective. “This is a capitalist country,” my cousin told me tartly, when I asked why she opposed a health-care reform measure under discussion a few years ago. She’s not alone in her revulsion at the thought of “socialized medicine,” and there are powerful lobbyists working hard to reinforce the notion that any change in the system will be exactly that, and that “socialized medicine” is not merely a bad thing but the worst construct devised by the mind of man.

Mr. Obama has his work cut out for him, and I daresay it’s his awareness of this mindset that restrains his ambitions to change the health-care system in America. His opening bid is more modest than the one Candidate Hillary proposed, because he knows he’ll be negotiating with some very tough characters. They smashed Mrs. Clinton’s plans, 15 years ago, with the result that nothing was changed, and Americans continue to pay more for less care, and the care we do get is less effective: our infant-mortality rate, for example, compares with that of Second- and Third-World countries. And there are plenty of insurance and pharmaceutical executives, plenty of doctors’ associations, and whole armies of lobbyists eager to keep things this way, and to spend heavily to persuade Congress to agree with them.

Yet these aren’t the biggest opponents that the President and any reformer must face down. The two real culprits are older, more deeply entrenched, and impossible to dissuade: the Pilgrim and the Cowboy. Both in what they believed and in what we believe about them, the Pilgrim and the Cowboy are powerful influences on American thought about health care — though I’m not sure we realize that.

You’re in good hands with the Almighty:

A different kind of insurance policy?

Since the days of our Pilgrim Fathers, Americans have believed that illness is a sign of personal weakness, even one of God’s disfavor. Why on earth would we as a nation pick up the tab for the medical care of a sinner? Never mind that this attitude is analogous to believing that illness is caused by Evil Spirits: it’s our attitude, and we’re slow to relinquish it. Look at an overweight person and try telling yourself that he isn’t responsible for his fat, try convincing yourself that obesity isn’t a symptom of lack of restraint, try not to mock him when he says, “It’s a glandular condition.” Just try it. You can’t do it, can you? The Pilgrim within you won’t permit it. And so you blame the patient for his illness.

(This attitude was rampant during the early years of the AIDS crisis, of course. If the patient had possessed sufficient rectitude to refrain from drug abuse or ungodly homosexual activity, he wouldn’t be in this jam, would he? And so we let thousands die.)

He cast a long shadow.

What the Cowboy actually believed is almost irrelevant: because of Hollywood movies about him, we believe that he rode tall in the saddle, even when he was sick or wounded. He was so manly that he wouldn’t reveal his pain. And so Americans associate illness not merely with moral weakness, but with physical weakness. We feel contempt for the patient. A kind of Social Darwinism sets in: “survival of the weakest” is not a winning slogan.

I have no idea how to change these attitudes, but I recognize their existence — something that few people I speak with ever do. Living in a country where preventive care is the norm, I see that it’s also more efficient: curing an illness is more expensive than preventing one. Americans don’t seem to grasp that concept. The French actually talk to their doctors — and to their pharmacists. Americans go to the pharmacy and buy over-the-counter remedies in secrecy and perhaps shame: we mustn’t let anyone know we were weak enough to catch a cold, so we buy Contac and scurry to the checkout quickly, before anyone sees us. The French engage in long discussions with the pharmacist (“Is this remedy better than that one?” “This is how you use this, and remember to be careful if you’ve got condition X, Y, or Z”); in many cases, customers arrive at the pharmacy with a prescription for a specific remedy, because they’ve already been to the doctor, whom they paid the flat rate of 21 Euros for an office visit, because they’re insured, because everybody’s insured. I had a hard time believing the amount of personal attention the French get at every step of their health care, while Americans are left pretty much to their own devices. From conversations, I gather the French are far happier with their health care than Americans are with theirs.

Pharmacien français: à votre écoute

Americans may be a long time understanding that “socialized medicine” doesn’t have to mean Orwellian bureaucracy or Sovietic privations, that while no system is perfect, there are degrees of awfulness: the French system seems pretty good, the American pretty awful.

But then, the French didn’t have Pilgrims or Cowboys to contend with. In order to heal ourselves — and our system — Americans will have to start by healing those guys.