TOWARDS AN ALTERNATIVE DEVELOPMENT OF HEALTH CARE A Dissertation Presented By ...

399 Pages·2006·2.76 MB·English

CARE IN THE COMMUNITY ECONOMY: TOWARDS AN ALTERNATIVE
DEVELOPMENT OF HEALTH CARE

A Dissertation Presented
By
STEPHEN HEALY

Submitted to the Graduate School of the
University of Massachusetts Amherst in partial fulfillment
of the requirements for the degree of

DOCTOR OF PHILOSOPHY

September 2006

Department of Geosciences
© Copyright by Stephen Healy 2006
All Rights Reserved
CARE IN THE COMMUNITY ECONOMY: TOWARDS AN ALTERNATIVE
DEVELOPMENT OF HEALTH CARE

A Dissertation Presented
by
STEPHEN HEALY

Approved as to style and content by:
_________________________________________
Julie Graham, Chair

_________________________________________
Richard Wilkie, Member

_________________________________________
Myrna Breitbart, Member
_________________________________________
Michael Williams, Department Head
Department of Geosciences
DEDICATION

To my father, who taught me the meaning of care.
ACKNOWLEDGEMENTS
There are too many people for me to acknowledge, all of whom have
contributed to my development as an academic, a thinker and a writer. All of
whom through their attention and care have given this project its depth of
meaning. Julie Graham’s tireless commitment to my scholarly development takes
shape in my mind either as a debt that cannot be repaid or as a gift that I must
accept with as much grace as I can. I must give heartfelt thanks also to Richard
Wilkie and Myrna Breitbart for there encouragement in this project over the
years—challenges, suggestions and invitations to think differently that helped me
on my way. I would also like to thank Rose Heyer for her support over the years,
her clarity in expressing “the point” of this project when I could not see it. Thanks
to Ken Byrne and Meredith Gray for tireless patience in editing previous drafts,
clarifying my aims, and objectives. I would like to extend special thanks also to
Yahya Madra—whose enthusiasm for our shared work and psychoanalysis proved
indispensable. I should also like to thank my family for their support and
encouragement. Many thanks also to Ceren Özselçuk, Joe Rebello, Becky Forest,
Peter Tamas, Chizu Sato, Kenan Ercel, Maliha Safri, Anasuya Weil, Gabriella
Delgadio, Greg Horvath, Brian Bannon and other members of the Community
Economy and Subjects of Economy seminars for the intellectual inputs that helped
the development of my work. Finally, I would also like to take this opportunity to
express my gratitude to my interviewees and friends. It is their insights that I am
trying to express in these pages, however tentatively.
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ABSTRACT
CARE IN THE COMMUNITY ECONOMY: TOWARDS AN ALTERNATIVE
DEVELOPMENT OF HEALTH CARE.
SEPTEMBER 2006
STEPHEN HEALY, B.A., HAMPSHIRE COLLEGE
M.S., UNIVERSITY OF MASSACHUSETTS
PhD, UNIVERSITY OF MASSACHUSETTS AMHERST
Directed by: Professor Julie Graham
The health care reform debate in the United States is defined by the choice
between free market reform and a government-administered single payer
alternative. Nearly half the population receives access to health care through
government directed programs (e.g. Medicare) while the remainder is covered by
private insurers. In spite of the current mix of allocation mechanisms advocates on
both sides of the debate have argued for the superiority of one form over the
other in controlling costs and constraining aggregate demand. Precisely because
allocation is the focus of the debate, “health care” is conceived of as a cost
incurred by businesses, individuals and/or the government. A miserly attitude
prevails.
This dissertation aims at developing a new discursive context in which to
politicize health care reform. I have used qualitative research techniques to
explore the spaces in which health care is produced, allocated and consumed. The
concept of the diverse/community economy, developed by J.K Gibson-Graham
and the Community Economies Collective, provides us with a language for
differentiating the economic landscape. This typology not only allows us to
recognize the importance of informal caregivers in the economy of care but also to
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recognize the different organizational forms, processes of exchange, ethical
commitments in health care’s “market sector.”
A common theme has emerged from my interviews with informal care
providers, physicians, community based health care institution administrators and
alternative practitioners. All of these people spoke of their ethical commitment to
care, how the practice of caregiving is deeply affecting. Interviewees recognized
that caregiving was at moments a source of profound meaning while, at other
times, it was a threat to their emotional and physical wellbeing. This dissertation
concludes with an argument for thinking of health care “reform” as a process of
development that focuses on the affective intensity of care and the ethical
commitment of care providers. The aim of this development project is to produce
supportive conditions for caregivers operating in both the formal and informal
settings to be ethically engaged subjects.
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TABLE OF CONTENTS

ACKNOWLEDGEMENTS...............................................................................................v

ABSTRACT.....................................................................................................................vi

LIST OF TABLES.........................................................................................................xiv

LIST OF FIGURES........................................................................................................xv

CHAPTER

I. HEALTH CARE REFORM AS DEVELOPMENT..........................................................1

Introduction............................................................................................................1

Motivation...........................................................................................................3

Disparities and Other Unmentionables.................................................................4
Health Care, Miserliness and Generosity............................................................10

The Miser......................................................................................................11
Caregivers, Oprah Winfrey and Generous Souls........................................13

Psychoanalytic Geographies and Care................................................................18
Diverse and Community Economies...................................................................24
Chapter Outline....................................................................................................27

II. HEALTH CARE AND THE FANTASIES OF REFORM............................................31

Introduction..........................................................................................................31
Patchwork Systems, Too Many Explanations, Endless
Recriminations......................................................................................................34

Explanation One: Partisan Rancor...................................................................35
Explanation Two: Labor’s Reluctance.............................................................38
Explanation Three: Complexity Itself..............................................................42

Fantasy as an Alternative Explanation................................................................43

Discourse and the Symbolic Order.................................................................43
Fantasy and the Failure of the Symbolic Order..............................................46

Wish to Live Forever vs. the Wish for Humane Care.................................48
Wish for Universal Access vs. Controlling Costs........................................49

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The Psychoanalytic Function of Fantasy: Castration and the
Conservation of Desire....................................................................................50

Analytic Intervention............................................................................................53

Moral Hazard and Demand Inducement........................................................55

Demand Inducement....................................................................................56
Moral Hazard................................................................................................59

Demand Inducement, Moral Hazard and the Real.............................................61

MCOs and the Domestication of Scarcity.......................................................63

MCOs, Doctors and Hospitals......................................................................64
MCO and Pharmaceuticals...........................................................................66
MCOs and Patients.......................................................................................68

MCO Meltdown and the Reemergence of the Real........................................69

Health Care Reform, the future of Fantasy.........................................................70

Educating the Consumer: HEDIS and its Audience........................................71
Health Savings Accounts and Consumer Driven Health Care.......................73

Market Segmentation and the Return of the Real..............................................75
Contemporary State of the Universal Alternative...............................................77

III. THE ECONOMY OF DIFFERENCE AND COMMUNITY IN
HEALTH CARE: THEORY AND METHODS...............................................................82

Introduction..........................................................................................................82
Uncanny Moments in Health Care Reform Discourse.......................................85

Unexpected Desires: Patients at the End of Life............................................85
Patient as Participant: Complementary and Adjunctive Care.........................87
Different Places: Informal Caregiving.............................................................88

Content in Search of a Form: Health Care in the Diverse
Economy...............................................................................................................92
Theorizing the Diverse Economy: The Rethinking Economy
Project (REP)........................................................................................................96

Confronting Capitalocentrism: Origins of the CEC and the REP...................98

Feminist Beginnings.....................................................................................99
Class Difference..........................................................................................101
Other Sources of Heterogeneity in the Economy.....................................105

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Four Stages of the Rethinking Economy Project..............................................110

Stage 1: Economic Genealogy.......................................................................111
Stage 2: Charting the Diverse Economy........................................................117
Stages 3 and 4: From Research Outcomes to Alternative
Development..................................................................................................120

Collective Copies........................................................................................122
Nuestras Raices...........................................................................................123

Listening for Difference in Health Care: Methodology....................................126

Asking the Right Questions...........................................................................128

The Interview Process................................................................................128
Transcription and Analysis.........................................................................130
Interviews...................................................................................................131

IV. AFFECT, DUTY, ETHICS AND INFORMAL CAREGIVING: THE
ROLE OF COLLECTIVTY AND GENEROSITY..........................................................134

Introduction........................................................................................................134
Subjects of Care: From Affect to Ethics.............................................................139

Towards a Definition of Affective Labor.......................................................140
The Importance of Being Affected................................................................143

Ethics, Duty, Care, Symbolic Death and the Affective Event..........................152

Ethics and Duty..............................................................................................153
Ethics and Transgression...............................................................................159
Ethics and Symbolic Death............................................................................161
Ethics and the Event......................................................................................164
Ethics in a Supportive Context: Noncapitalism and Generosity..................165

Becoming a Caregiver: Ashley and Anasuya....................................................169

Ashley.............................................................................................................169
Anasuya..........................................................................................................179

Unpaid Caring Labor, Provisional Conclusions................................................183
Unpaid Caring Labor and Class Analysis..........................................................184

Feudal Caring Labor?..................................................................................189
Independent Caring Labor?........................................................................191
Communal Caring Labor?...........................................................................191

A New Approach to Reform: Generosity and Communality.......................192

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