Religion, contraception, and health insurance

In the US, there are two ways most of us get health insurance: through Medicaid (53 million enrollees) or Medicare (nearly 45 million), or through an employer (148 million).

That’s 44% of us relying on health insurance through our jobs, and the federal government has regulated this area for a long time, including mandating the inclusion of certain types of care. Nixon signed the Health Maintenance Organization Law of 1973, designed to encourage the formation of HMOs to provide medical care and contain costs. HMOs were required to deliver “basic health services” including mental health (maximum of 20 visits), medical treatment and referral for alcohol and drug abuse or addiction, home health services, and preventive services (vision care and preventive dental care for children, and family planning services). Other providers of health care for employees

Another 16% of the population receives health care through Medicaid, which is paid for jointly by the federal government and each state. States design their plans but must obey federal rules, which since 1972 have required that states include “family planning and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active)” to Medicaid eligible individuals. Though Medicaid coverage of prescription drugs is generally an option for states, contraceptives are specifically included under the mandate and therefore are required for all state programs. [This information is from a joint report by the Kaiser Foundation and the Guttmacher Institute; at the end of the post there appears an excerpt which summarizes why family planning was mandated.]

So, there is nothing new about the federal government requiring health care organizations such as HMOs to offer contraception, and every person or business paying state or federal taxes is supporting contraception dispensed by Medicaid.

What’s new is the government requiring that employers offer health care, and that the health care include contraception. Previously, we must suppose, religious organizations opposed to contraception have chosen health care plans that don’t cover it. Now, for good public health reasons (see the report excerpt at the end), that loophole is being closed.

Obama’s response to criticism of this requirement—criticism marked by hyperbole, e.g. calling it a “war on religion”, and a violation of freedom of religion—has been to say that the services must be offered, but no religious organization has to pay for contraceptive services: the insurance company must absorb the cost itself. Catholic bishops still object, and say they will take the issue to court, partly because some religious organizations are self-insured; no insurance company is involved. But as we have seen, if the churches are paying any taxes (sales tax, property tax on buildings they own and rent out, etc.) they’re already paying for Medicaid’s family planning, from counselling to IUDs and pills. If their court case succeeds, will they then file to be exempted from taxes that support Medicaid?

If Obama’s accommodation is the right solution, then surely we should exempt the Christian Science church from paying for health care insurance at all! And following this precedent, the rest of us should demand the same sort of line item veto for our income tax so we can opt out of paying for this or that war, for the agencies enforcing laws about civil rights and equal employment, for the next bank bailout, for federal aid to schools that teach sex education or evolution, for whatever we don’t personally like or need. The Tea Partyers will love this!

Coffee dyed paper

Below is the excerpt from the Kaiser Foundation/Guttmacher Institute report, Medicaid’s Role in Family Planning (2007).

Medicaid  family planning, excerpt from Guttmacher report at http://www.guttmacher.org/pubs/IB_medicaidFP.pdf

Cymbalta and fibromyalgia, my experience

Since being diagnosed in 1992 I’ve tried quite a few medications hoping they’d help the symptoms of fibromyalgia. Only two have made the cut; most of the others had no effect, or (like pregabalin and Lyrica) were too sedating to find out if higher doses would work.

Currently I take only two medications for fm: a very low dose of trazodone, an old (generic and cheap!) anti-depressant, to help me sleep, and a new anti-depressant, Cymbalta. The Cymbalta is actually for depression. I began it after the previous anti-depressant, Celexa, stopped working. I didn’t know it had stopped working, I thought I was just feeling how I felt. Dark horizons closed in on me and I saw that life really was merely a period of pointless suffering, so I told the doctor who prescribes for my depression that I thought I might as well quit taking anything and just experience reality. Afterwards I was embarrassed at my lack of insight into my own mental processes, but by its nature depression’s a condition that disables self-analysis and replaces it with the exquisite existential pain of being alive and aware. This is why depression thrives on the isolation it so effectively induces.

To be honest I must say I still feel there’s a strong intellectual case to be made that “life is merely a period of pointless suffering”… except that the medicated me retracts the word “merely”. And knows that the intellectual perspective is not the whole picture. Like an extremely protracted wait in an airport, life can be viewed as just something to endure, or you can notice what’s going on around you, help out some other travellers, go explore a different part of the airport, meet other people, and so on. Then, indeed, you die. But in the meantime, why not make the most of where you are? There are pleasures to be found, skills to master, a marvellous natural world of birds and bugs and clouds, and considerable satisfaction in doing something that lessens the overall quotient of crappiness and suffering. It’s even possible to find other people whose company you enjoy, people you love.

But without a functioning anti-depressant, I did not feel this way. So is it the “real me” speaking now, or just a chemical? Or was it a chemical imbalance that made me feel even worse than this guy (Joe Btfsplk, from Al Capp’s Li’l Abner)? Irrelevant hair-splitting. Unproductive line of investigation. Phooey on it.

Joe Btfsplk, Al Capp's character with a black cloud over his head always raining misfortune on him

Okay, so, Cymbalta works for me (for now) as an anti-depressant, but what about the fibromyalgia connexion? It’s touted as a drug that helps with fm pain, which is why my doc and I agreed on using it despite its expense. At first I noticed no difference. Pressure is still pain, it hurts to hold onto the steering wheel or lean against a wall or sit or stand. Then the doc asked me, after using it for the better part of a year, if it had helped the fm. Didn’t really think so. Later, I looked back over what has changed in that period and there’s one huge thing: I have been able to stick with an exercise plan of walking, to the point where I could walk 2 miles with the first mile being all uphill. And when I challenged myself after a while to walk the uphill mile without stopping I found I could. Always before, no matter how gradually I increased the exercise, within a couple of weeks (or less) my pain and exhaustion would spike so much I’d have to stop for 5 or 6 days. You never get any “training effect” that way. You’re always struggling and always being knocked back to the starting point. This fantastic feature of fibromyalgia (and of chronic fatigue syndrome) is called post-exertional malaise.

Unlike my previous anti-depressant, Cymbalta (Duloxetine) doesn’t just increase the amount of serotonin available in my system, it does the same thing for norepinephrine. What does this mean? Here’s a clue: norepinephrine is also called noradrenaline. It’s secreted by the adrenal glands and, along with adrenaline, it has actions throughout the body and also in the brain, mostly aimed at revving you up—increasing heart rate, blood pressure, and blood sugar; raising the metabolism; in general, preparing the body “to take immediate and vigorous action”.

Since even the researchers aren’t sure exactly how anti-depressants “work”, I’m not going to delve into it any further here. Suffice it to say that some part of norepinephrine’s action enables my body to deal with exercise more normally, and adapt to it. My walking muscles have gotten stronger, my aerobic endurance has increased, and I’ve even gotten to where at the top of the hill when I branch off onto a level road to cool off before the descent, I feel really good! Like I could walk for hours! That’s something I never thought I’d experience again, the enjoyment of physical exercise and of getting a little fitter each time. It’s probably partly the oft-mentioned endorphins that those smug runners get, and partly personal satisfaction at achieving the goal once again.

Each time it gets a tiny bit easier. At first when I started doing the uphill half without stopping I was flogging my body onward, unconscious of anything around me, totally absorbed in persevering. I had to sit down at the top, out of breath and exhausted. Now, I walk on for another 15 or 20 minutes (not uphill—yet!) without difficulty and then head back. Sometimes I have minor muscle soreness that lasts a day or two, and one knee protests that it is too old for this, but I’m not in pain and drained of energy for days as I used to be (prior to Cymbalta) after doing short level walks.

The catch about Cymbalta is the expense. I take a high dose, 160 mg/day, and it costs about $10 a day. (Last quarter the manufacturer, Eli J. Lilly, made profits of $1.2 billion on total revenue of $6.25 billion; 20% profit, not bad.) My insurance, the Medicare Drug Plan, covers most of it and so do some regular health insurance plans. It’s prescribed for depression, fibromyalgia, neuropathy, and some forms of chronic pain. There will be no generic version until the patent expires in 2013. Online ads for generic cymbalta should be regarded as scams, as if someone wanted to sell you $20 bills for $5. It can’t be the real thing from the manufacturer, and you have no idea what it might be.

There is an organization, The Partnership for Prescription Assistance, which “helps qualifying patients without prescription drug coverage get the medicines they need through the program that is right for them. Many will get their medications free or nearly free.” This organization is sponsored by America’s pharmaceutical research companies. There is no charge for getting help from the PPA. You can find more information about them here. Your doctor may know about other ways to save money on prescriptions; ask! Also, inquire about free samples to get started and see if it helps you.

Daydreaming—my brain didn’t get that module

Until I read an article in Scientific Mind this month about daydreaming (“Living in a Dream World” by Josie Glausiusz; not available for free as far as I can find), I wasn’t aware that I lack this mental activity. Definitions vary; one used in the article is that daydreams are “an inner world where we can rehearse the future and imagine new adventures without risk“. Another is “imagining situations in the future that are largely positive in tone”. I would add something to differentiate daydreaming from planning—perhaps that daydreaming includes emotional reactions.

It’s not clear in the article whether research results apply only to positive fictional imaginings or to routine planning and review, as well. The latter is much more common. Also the author conflates daydreaming and the mind’s use of off-task time to solve problems non-consciously.

People can daydream in extravagant adventures à la Walter Mitty, or more mundane imaginings of how good that hot bath will feel after work, or how happy one’s child will be when she receives her Christmas present. Most people, the author says, “spend about 30 percent of their waking hours spacing out, drifting off, lost in thought, woolgathering, in a brown study, or building castles in the air.” And it’s important to our sense of self, our creativity, “and how we integrate the outside world into our inner lives”.

I remember, as a solitary child, pretending to be Superman or Tarzan, but not often; I read, instead. After the age of 10 or 12, I don’t think I had imaginary adventures at all. Not surprisingly, I’m also unable to visualize scenes: “Imagine yourself on a tropical beach” is impossible for me to do. I can think, okay, I’m on a tropical breach, it is warm and sunny, and so on, but there’s no sensory aspect to it, just words. Similarly, my memories of the past (mostly gone now due to fibromyalgia cognitive damage) are all just words, as if someone had described a scene to me rather than my having experienced it. There’s no “mind’s eye” in my mind. In novels I usually tune out while reading the descriptions of landscapes and people; no corresponding mental pictures rise in my mind.

Daydreaming can be escapism but it can also be a way of trying out different futures, and experiencing the associated emotions. I think this could also help motivate a person toward a chosen or hoped-for future, by allowing advance tastes of its rewards or of the misery of its alternative. I make decisions about future choices and I make plans but I don’t try them out mentally in advance, and I also (in jobs, for example) tend to stay where I am rather than striving for something different. I’ve thought of myself as lacking in ambition, but maybe it’s more that I don’t have a way of modelling the future choices with emotional content. Mostly I’ve stayed in jobs until they became intolerable, then moved on, sometimes with no replacement in mind. I can’t even really visualize ideas for a vacation or a trip, especially to someplace I’ve never been.

So, what do I do with that 30% of my waking hours that other people use for daydreaming? Not enough. Sometimes, for a couple of minutes, it seems nothing is going on in my mind, or merely observation, without commentary, of what’s happening around me; I have no idea how typical that is. But mostly the engine’s running, chewing over what’s in front of it. Why are things this way, how could this activity be done better, how does this work, that sort of thing. I used to do a lot of sequential thinking, as if working through thoughts with pen and paper, exploring ideas and putting things together, taking them apart, finding correlations and causes. I could continue working on different mental projects during intervals across days and days, and sometimes wrote that way—at the end of the mental work I’d have an outline and some exact wording to put down on paper. Then I’d revise and expand, but I could work out a lot of it mentally and recall it. No more, since fibromyalgia. Thinking is often slow and I can’t remember from one day to the next what I came up with. Sometimes thoughts flit through and are gone before I can even try to remember them. This is one of FM’s major losses, for me, both a loss of pleasure and a loss of what I can accomplish.

Maybe reading fills the role of daydreaming for me. I read a lot, about equal amounts fiction and non-, and if circumstances prevent me from reading for a couple of days I feel the deprivation. The article mentions non-daydreamers only in passing: “Cognitive psychologists are now also examining how brain disease may impair our ability to meander mentally”. If my impairment is due to a brain disease, it’s one I’ve had since early on.

Others, it turns out, suffer from the opposite disorder, daydreaming that is a compulsion or simply so enjoyable that real life takes a back seat. Some have a second life in an alternate world where continuing characters age just like people in the world the rest of us live in. They may fit this narrative into available mental down-time in their lives, or spend up to 90% of their time “away”.

I find it strange that it took me so long to discover that other people spend a third of their waking hours on a mental activity which I lack entirely. It goes to show how little exchange there is among us humans regarding how we think, how our individual minds work. Humans yo-yo between xenophobia—members of other groups are different, dangerous— and “we’re all really just alike”, but a study of psychological research found “significant psychological and behavioral differences between what the researchers call Western, Educated, Industrialized, Rich and Democratic (WEIRD) societies and their non-WEIRD counterparts across a spectrum of key areas, including visual perception, fairness, spatial and moral reasoning, memory and conformity.“ Maybe in daydreaming as well. But nearly all psychological research is done on WEIRD subjects, for both practical and ethnocentric reasons, so who knows? Same for neuroscience; who’s going to airlift fMRI equipment to the lands of the Yanomamo and then persuade them to lie down with their heads inside?

ScytheSharpeningLeighton

Still, the article raised in my mind some questions we could look at right here in the post-industrial West. If people were prevented from daydreaming, by some technological device probably not yet invented, how would they feel? (Recalling the familiar ‘fact’ about deprivation of night-time dreaming making people hallucinate, I looked to see if it was true, and apparently not.) What proportion of people don’t have imaginative daydreams, and is this always a sign of brain disease or dysfunction or just a normal mental variation? We characterize one sort of excessive negative daydreaming as “catastrophizing”; what about individuals making deliberate use of negative or positive futures, to influence their behavior? And how can “daydreaming” be more precisely separated out from other mental processes such as planning, brooding, brainstorming, and worrying?

Muse on it all, and see what your daydreaming mind comes up with.

King vulture

King vulture photo by Tambako the Jaguar, flickr.