Over the last 72 hours, I've been reflecting a lot on the US Healthcare System for... various reasons. Yesterday I had another experience with my own personal healthcare that, in light of recent events, had me seething. This is a situation I've posted about before, and here I was, once more, stuck in the bureaucracy of healthcare under capitalism, and I was reminded of Chapter 8 from Capitalist Realism entitled "There's no central exchange".
The closest that most of us come to a direct experience of the centerlessness of capitalism is an encounter with the call center. As a consumer in late capitalism, you increasingly exist in two, distinct realities: the one in which the services are provided without hitch, and another reality entirely, the crazed Kafkaesque labyrinth of call centers, a world without memory, where cause and effect connect together in mysterious, unfathomable ways, where it is a miracle that anything ever happens, and you lose hope of ever passing back over to the other side, where things seem to function smoothly. What exemplifies the failure of the neoliberal world to live up to its own PR better than the call center? Even so, the universality of bad experiences with call centers does nothing to unsettle the operating assumption that capitalism is inherently efficient, as if the problems with call centers weren’t the systemic consequences of a logic of Capital which means organizations are so fixated on making profits that they can’t actually sell you anything.
It has been three months since I needed to re-up on my ADHD medication. One major thing that has changed in my relationship with the US Healthcare system is my primary care doctor. It was naive of me to think that this would have minimal impact on acquiring the Schedule 1 drug I take to regulate my mind and emotions. I even mentioned my frustration with this three month ritual I perform while at my intake appointment. I was told, "Just call us a week ahead, and we'll make sure you get your script on time." I think you understand where this is going.
Getting my specific prescription requires me to interact with at a minimum with three organizational entities. The most it has required me so far has been four organizational entities. Each of these entities has their own, Kafkaesque labyrinth of internal bureaucracy that I need to carefully and artfully maneuver through, and failing to maneuver through one of them creates a cascading failure state that requires the whole process to start again.
The call center experience distils the political phenomenology of late capitalism: the boredom and frustration punctuated by cheerily piped PR, the repeating of the same dreary details many times to different poorly trained and badly informed operatives, the building rage that must remain impotent because it can have no legitimate object, since – as is very quickly clear to the caller –there is no-one who knows, and no-one who could do anything even if they could. Anger can only be a matter of venting; it is aggression in a vacuum, directed at someone who is a fellow victim of the system but with whom there is no possibility of communality. Just as the anger has no proper object, it will have no effect. In this experience of a system that is unresponsive, impersonal, centerless, abstract and fragmentary, you are as close as you can be to confronting the artificial stupidity of Capital in itself.
The process starts with my doctor's office. Following previously understood norms learned from a previous doctor's office, I call the front desk to request a refill on my prescription. Here is where false hope takes hold, as the process is simple and straightforward. I tell the receptionist I'm getting a refill, she asks me for identification, I provide, she asks me for prescription details, I again provide, I also include some clarifying statements such as "I know I'm a new patent here, but in my previous office they would fill me a script for 90 days for my convenience." I also tell them, "I'd like this to be sent to the mail order pharmacy, they have been reliable for me in the past." I'm assured that information will get passed along. The call ends, and having been through this dance before, I do not allow false hope to find a place to roost within my thoughts.
From here, the issue of getting my prescription filled is out of the hands of the first organization. When this request fails, and it will fail, they can absolve themselves of any issue. Having been here before, I know how this game is played. Neither organization wants to take any ownership of the transactional failure that happens between them. This is the first sign of the power of capitalism's horizontal organization. See, neither of these organizations are subordinate to the other, and as we'll see, this is true for the other two organizations involved as well. Not a single one of these organizations has any understanding of the rules and structure of the other's internal labyrinth. That is not for them to know or understand, it does not benefit them to do so. That burden is given to you, as you are the only one who stands to benefit from running the maze and getting the cheese. You see, you are the rat in the maze, and the way you interact with the maze informs the observers on how well the maze is built and what needs to be changed. This maze is not constructed for convenience, and paradoxically, it is not constructed to facilitate you getting the cheese. Often, the cheese at the end of this maze might result in you receiving some form of monetary restitution, but even when the goal is to provide you with a product which you can consume, they will build these mazes almost as a kind of natural byproduct of the internal conflicts within capitalism. Contacting the interior of the organization, and getting to a human, could place the organization at risk of almost anything, and I have to wonder if this maze is built as a kind of defense mechanism that ultimately undermines their own stated goals of earning profit.
Some time passes, and naturally, I have no information about the status of my request. It is gone into the black void of the capitalist bureaucracy. Their mobile apps function as another limb on the money tree for these organizations, gathering information that can be used against you to yield a more fruitful blossom come the spring. While dealing with one of capitalism's other failures yesterday, I happened to remember I placed a request for a prescription, and checked the mobile app for the mail order provider I use. Once opened, I was met with what I expected, a notice that my prescription had been "canceled". The obvious first question is "Why?" and naturally, the mobile app is not here to provide you with those answers. The Mobile app is also not responsible for notifying you in any reasonable way about the cancelation of the request, maybe this is a privacy issue, HIPAA perhaps. A simple "A prescription has been canceled" would have been enough, but I guess that would cut into their earnings somehow. So, back into the labyrinth I delve yet again, but this time inside the organization tasked with filling this prescription.
"The supreme genius of Kafka was to have explored the negative atheology proper to Capital: the centre is missing, but we cannot stop searching for it or positing it. It is not that there is nothing there – it is that what is there is not capable of exercising responsibility."
Here is where the call center shines, and I am met by a very pleasant individual. They take my information to verify I am who I am, and then proceed to ask me why I'm calling today. When I explain that one of my prescriptions was canceled, and then tell them I'm looking to find out why, almost as a knee-jerk response, in the nicest tone one can imagine they say:
"Oh, I don't know why it's canceled."
I have to suppress every nerve in my brain stem that wants to erupt over this statement, and remind myself this person is also a victim of these systems, as much as they are a part of them.
"So, there is no information about why it was canceled?",
"Here, let me look it up."
This response, again, is telling. Were they being literal in their previous statement, that they did not know why it was canceled because they had not looked it up? That is probably the most generous interpretation of this exchange, but I highly doubt that's the case.
"Here it is. There is a note on it... let me see... The note says something about it not being within the plan minimum. I'm not sure what that means exactly."
What is clear throughout this exchange (which I have truncated) is that this person is only the facilitator of prescriptions once they are approved. How they become approved, and for what reasons they are denied, that is not their role. In fact, no one really knows why things happen the way they do within this organization. They simply abide by rulings that come from another organization, of which they have no authority over. This, "note", is likely the result of some response from the insurance company. It is not the pharmacies job to advocate for the prescription to get filled. It does not matter how often they see this exact issue, they intake prescriptions and process only the approved ones. Furthermore, it's also not the job of the doctor's office to ensure the prescription gets filled, they are simply the ones writing the prescription, even if they constantly encounter this exact issue. They simply intake sick patients and at times output prescriptions for someone else to process. The insurance company's only job is to evaluate a request in effectively a vacuum against rules only understood by those inside its organization. The insurance company intakes requests and outputs rulings and money to compensate the other parties, and it hates outputting money.
Each organization has its own rules they must abide by, and none of those rules are in service of providing you adequate healthcare. It is not a "farm to table" operation where you see the doctor, who puts in a prescription to an in-house pharmacist, who gets approval from an in-house insurance representative, all working under the same hierarchy, with the common goal of getting your prescription in a timely manner while abiding by all the rules and regulations impact them externally. Under our liberal economy, that would be described as a "monopoly" which "stifles innovation and competition". Yet so many of these three entities, Doctor's Offices, Insurance Providers, and Pharmacies are owned under much larger medical umbrellas, and because of the horizontal nature of their arrangement, it somehow doesn't constitute a monopoly as such. Just because each of them has a publicly traded stock or external investments that are all owned by the same source, doesn't in any way imply that they are centrally owned and operated. Besides, even if that were true, those investments are coming from an investment firm whose only job is to intake corporations and output return on investments.
So from here we've hit the end of the line. We have to return to the start position, and call into the doctor's office, where you will be met with a nice receptionist who dutifully takes your notes and sends them off to the "appropriate people". This time, however, you have a different plan. You see, each time you delve into the maze of one of these organizations, you don't always leave empty-handed. You might not have gotten the cheese, but the wandering souls that shift and change the shape of the maze will also be willing to provide you with information. This resource is the only form of currency you have to make the interlocking gears of this clockwork nightmare spin for you. Every time you pass through the call center gauntlet and reach a real human soul, it is your job (not that anyone will tell you this) to interrogate them as long as they are willing to stay on the phone. You have to be cunning, though, and you can't fall for the traps that they lay. It is unclear how much of this dialect they speak is deliberately taught, or if it develops over time as a kind of release pin to get you off the phone as fast as possible.
"I know that the pharmacy has that medication, you might want to have it sent there, if you're worried about time."
"That's true, so you can see that they have the medication in stock? I know that it can be difficult to find these days."
You have to ask these kinds of questions instead of assuming what they said is what they meant, you learn over time that if you were to hang up now, you still do not have enough information to be successful down the line.
"Oh, no, sorry, the system doesn't let me see what they have in stock. I can just see that they have it."
They have it, but not in a way that indicates to this person that they have it if you catch the drift. This again is because, even though this company, and the local place bear the same name, they are not in the same business and not connected in any meaningful way. You would think a decentralized system such as this would have supreme interoperability, but that's the preview of federated web forms, and not the healthcare system. From here, you now know what you need to do next, and we are now engaging with our third organization, a local pharmacy that lives under the same umbrella as the mail order pharmacy.
This is where true capitalist innovation is on full display. You see, local establishments in the physical reality are some of the easiest methods of infiltrating the maze and contacting a real human soul. The issue, however, is time. Many of us understand this, and for others less fortunate than myself, they must drive for an hour or more just to walk through the doors of this holy space. So often, while between tasks, toiling away as helpless souls reshaping our own personal labyrinths, we make a phone call to these places. Instead of being greeted by a nice receptionist or a queue, we are greeted by the perfect little worker. The Fully Automated Phone Attendant. This automaton has become quite sophisticated over the years. Gone are the days of a directory of selections, and here are the days of completely authentic voice communications with a robot whose only job is to gate keep your access to a human. It isn't just pharmacies either who have implemented this form of innovation. Even your favorite, local, national, pizza place no longer accepts incoming calls to their physical location. Now, you are met with a centralized automaton ready to take your order, and if they should fail, shunt you off to the far-flung corners of the globe, where someone from the global south will carefully read you a script for pennies an hour, all so you can get a nice slice of pizza pie. Anyway, I digress. Here, you might have picked up some knowledge, that can expediate your attempts at bypassing this system. Maybe this robot still responds to key presses, such as mashing the 0 key to get the operator, perhaps this robot understands "frustration", and unleashing a volley of obscenities that would make Donald Duck blush will get you to a human, or potentially you know the direct internal extension that makes the pharmacy phone ring.
Once on the phone, you attempt again to fish for information, knowing full well these poor souls are deeply underpaid and understaffed. You have to tread lightly, as to not set off a hair trigger that has manifested from the stress they live under. Again, you present your information so that, again, you can be identified within their system. This time, the universe sent me a hurdle. A bit of cosmic capitalist jazz demanding some improvisational thinking.
"Yeah, hi, so I'm just calling to see if you have medication in stock. I know that it can be difficult to come by but ..."
"Well our systems are down, so .... not sure when they'll be back up, someone is here working on it."
"I see... So no one, even offhandedly, would know if you have that medication in stock?"
"Let me ask the pharmacist..."
I know that I have reached the most working-class parts of this web, and for that, I do have sympathy, but even here we must recognize that this exchange will be shaped by the internal nature of the pharmacy. This person has scripts to fill, customers to talk to, and almost no backup. Dealing with me on the phone is the last thing they wish to do, and the phone is the safest place for a verbal assault to happen, which I'm sure also shapes their response.
"Yeah, we have it..."
Mission complete. Again, I start back at the beginning, and the exchange is nice and simple. I expand on the request, letting the doctor's office know that... this isn't the first request, and I've encountered road blocks that seem to result from their office and their choices, but these notes are likely not translated in a way that conveys the frustration I've just endured. Interestingly, a day later, the prescription is filled, this time at the local pharmacy as I requested, and it is processed without issue, even though it is the same prescription for the exact quantity of pills. Shouldn't this be "outside of plan minimums?" I wonder as I wait for the price to appear after picking them up. I see that I'm only paying the copay, and I'm left wondering if I'm getting away with something, or if something more sinister is looming on the horizon, ready to lure me back into the maze.
In the end, I've received a prescription at a lower pill total than I would like, and for whatever reason, still at the "outside of plan minimum" quantity, even though I specifically said this quantity was causing problems. "Why were these choices made by the doctor?" I wonder. Through this whole process, I did not speak with them once. Now this curiosity has me back into the maze again, this time searching for the doctor and not the cheese. This is all in preparation for the next round of maze running I have to do in 28 days, now that I've been shunted onto this monthly schedule.
The horizontal nature of capital allows for it to create these kinds of encounters and all of them are, in effect, blameless. These organizations operate on limited information, and when something goes wrong, it is the fault of the other organizations, and not their own. There is no one to complain to. There is no manager who will want to "make things right". Blame can be shifted in any direction. You are the soul facilitator of your own healthcare, and if you were to sit idly by, thinking these interlocking systems even know of your needs, you'll be left for dead.
There’s no fixed exchange with the Castle, no central exchange which transmits our calls further. When anybody calls up the Castle from here the instruments in all the subordinate departments ring, or rather they would ring if practically all the departments – I know this for a certainty – didn’t leave their receivers off. Now and then, however, a fatigued official may feel the need of a little distraction, especially in the evenings and at night and may hang the receiver on. Then we get an answer, but of course an answer that’s a practical joke. And that’s very understandable too. For who would take the responsibility of interrupting, in the middle of the night, the extremely important work that goes on furiously the whole time, with a message about his own private troubles? I can’t comprehend how even a stranger can imagine that when he calls up Sordini, for example, it’s Sordini that answers.
K’s response anticipates the bewildered frustration of the individual in the call center labyrinth. Although many of the conversations with call center operatives appear Dadaistically nonsensical, they cannot be treated as such, cannot be dismissed as being of no significance.
‘I didn’t know it was like that, certainly,’ said K. ‘I couldn’t know of all these peculiarities, but I didn’t put much confidence in those telephone conversations and I was always aware that the only things of any importance were those that happened in the Castle itself.’
‘No,’ said the Superintendent, holding firmly onto the word, ‘these telephone replies from the Castle certainly have a meaning, why shouldn’t they? How could a message given by an official from the Castle not be important?’
