Pain (18 page)

A moderate on this disability issue, Carter was classically liberal on other pain concerns. Pushed by drug reformers to rethink Nixon's war on drugs, for example, the moderate Carter was open to reconsidering the government's strict ban on heroin as a painkiller. But in the realm of disability and welfare fraud, Carter staked out a tougher position, introducing a “welfare policing” system in 1979 called the National Recipient System. One report called it “the largest computer system to check on private citizens ever instituted by the federal government.” When combined with the continuing review of claimants, this initiative took earnest aim against corruption, waste, spending, and fraud in government.
¹²
But would these policies fix the “perverse incentives” in the system? Would they be enough, or had they already gone too far?

Led by Senator Edward Kennedy, the defiant political Left in control of Congress criticized Carter's policies as too quick to cut social welfare programs. Moreover, Carter had infuriated congressional liberals when he decided that pressing for a national health insurance was politically and economically unfeasible. Kennedy criticized the president publicly for a “failure of leadership.” By his third year in office, the conventional wisdom on Carter was that the moderate Southerner had tried, but failed terribly, at weaning Congress from its liberal ways—that his efforts had been frustrated by a Democratic political establishment intent on protecting the welfare state it had carefully built. On this topic, the dispute between the moderate and liberal wings of the Democratic Party had grown intense. In Kennedy's view, Carter had betrayed core liberal principles. The senator's anger led him to challenge the president for the Democratic nomination in early 1980, crippling Carter's standing with his own party.
¹³

Meanwhile, the political Right continued to lambast the administration's efforts as too modest and too ineffective, as timid and piecemeal. Writing for example in the
Chicago Tribune
, editorialists took aim at the disability program's “excessive generosity” and its skewed incentives, which supposedly contributed to a “waning of the work ethic.” “Take the case of a worker with two dependents and with a take-home pay of $8,259 after taxes. Under present law, if he quits work because of, say, a lower back pain, he is entitled to $7,774 a year in Social Security disability benefits—or 94 per cent of his former take-home pay.” In two years, the
Tribune
contended, these benefits would increase even more—so
much in fact that “only an incorrigible workaholic would want to go back to work.”
¹⁴

As both liberal frustration and conservative ire with Carter grew, Ronald Reagan stood poised to be the standard-bearer for Republicans in the 1980 presidential race. Reagan hoped to make the race a referendum on big government liberalism and welfare dependency. The intense lights of the campaign produced glaring (if oversimplified) polarities—bleeding-hearted liberalism versus coldhearted conservatism, compassionate Democrats versus fiscally responsible Republicans, and so on. Caught between these polarities, Carter signaled—in the middle of his campaign—that a reassessment of the disability system was in order. In June 1980 he signed a new law (H.R. 3236, the Social Security Disability Amendments) mandating that the Social Security Administration do more to encourage disabled citizens to return to work. In the president's view, the law was “designed to help disabled beneficiaries return to work by minimizing the risks involved in accepting paid employment.” In short, the new incentive offered more carrot than stick—assuring people on disability who doubted they could handle returning to work that they would not risk losing benefits if they tried and failed. They were assured of “automatic reentitlement to benefits” if the return to work failed within a year.
¹⁵
Protection in the event of medical mishaps was assured for three years. The rationale behind this policy shift was that the disabled truly wanted to work but needed coaxing. They were not welfare cheats, chiselers, or thieves—all they needed were the right incentives to find their way back into the workforce. Conservatives predictably decried these last-minute reforms as insufficient; as they saw it, the psychology of dependence was a deep cancer demanding much more drastic medicine.

If Carter's therapy seemed timid to Reagan supporters, Carter's followers saw the Right's medicine as draconian and gratuitously painful. Days before the election, Carter asked voters to consider Social Security disability as a bellwether issue, for it revealed Reagan's hard and compassionless heart. In the closing days of the campaign, he recalled Reagan's passionate opposition to Medicare and other social insurance programs. Reagan, he reminded voters, had called these programs “socialist” inventions that preyed on liberty and freedom itself. “Governor Reagan's first major experience in public life was to engage in an active, hard-fought
campaign against Medicare,” Carter noted. “Governor Reagan worked to convince the American people that Medicare, which protects all of us against medical expenses when we retire or are disabled, was socialism.” Looking into strong political headwinds predicting a Reagan victory on Election Day, Carter insisted that those who had built this system would never waver. They supported it because it promoted retirement with dignity not because it bred dependency: “I oppose cutting back basic social security and disability provisions on which most Americans rely … It protects almost all of us from disability and provides a hedge against dependency as we grow older … Governor Reagan can remember, as I can, when older Americans lived in constant fear of financial disaster, when men and women who had worked hard all their lives had to face a retirement without dignity.” In Carter's view, the election was about dignity, decency, and social justice. “I am proud to stand for social security and for decent health care,” the president concluded, “and I propose to continue the great fight for social justice in our country.” But Carter would not have that chance. A solid majority of American voters—most notably, the Southern Protestants who had supported Carter in 1976—ignored the president's warnings and elected Reagan in a landslide.
¹⁶

Taking office in January 1981 after his victory, Reagan began an artful two-step on the disability question: attacking liberalism with rhetorical vigor and withering humor, while also pointing to Carter's own reforms as precedent for his own Social Security review and cuts. Meanwhile, his HHS secretary expanded the continuing review process and ruled against thousands of people who had come to depend on regular payments. When congressional Democrats denounced the aggressiveness of these disability reviews, Reagan used Carter for cover. Noted the president, “There is the program of social security disability, and … in 1980, under the previous administration, a law was passed to try and clean up what was believed to be a gigantic abuse of that program. So, there are things that can be done.” But the goal of Reagan's policy went well beyond Carter's attempts to battle fraud and tweak skewed incentives: instead, Reagan proposed to reduce the size of government and the scale of dependency by the hundreds of thousands; to weed out chiselers, frauds, ineligibles, and anyone who could work for a living; to turn to the private sector for answers to all social problems; and, thereby, to promote a
conservative vision of America and its work ethic.
¹⁷
A pivotal and punitive chapter in the conservative politics of pain had begun.

Speaking at a press gathering in October 1981, Reagan used a shocking example to portray people on disability as profoundly undeserving of government support. Defending his Social Security policies before a group of out-of-town newspaper editors, Reagan explained that his administration was not pursuing major cuts but merely “clearing up some things on the periphery, such as people getting disability in Social Security that weren't entitled.” Putting a troubling face on the problem, he asked, “Doesn't it sort of strike you as strange that [serial killer] Son of Sam, serving that seventy-five-year sentence up there for all his murders, is getting $350 a month from disability, social security, because they say he's incapable of holding a job? And this is going on all over the country.” If any editor in the room had been confused about Reagan's views on disability claimants, they no longer had an excuse now. Son of Sam had been arrested in New York City a few years earlier, charged with several ritual murders that shocked and horrified the nation. As if this were not clear enough, Reagan offered the editors another example of waste, fraud, and disability abuse—again using the criminally insane: “We have people in California that I know of, in mental institutions for the criminally insane, who are drawing regular payments because, due to their mental illness, they had been judged incapable of holding jobs. But now, we're paying their room, board, medical care, and laundry, housing, and yet they're getting that payment.”
¹⁸
These were not rhetorical accidents but the kind of biting and exaggerated stories Reagan had told for decades, tying the disabled to deeply stigmatized people—to the criminally insane—as representatives of the failure of liberal society. For years his rhetoric had been a minority viewpoint within his own party, but now, speaking for a majority as president and policy maker in chief, Reagan was in a position to act against what he saw as this unconscionable fraud.

FIGURE 3.1.
Ronald and Nancy Reagan waving triumphantly during the new president's Inaugural Parade. Washington, D.C. January, 20, 1981.

Image courtesy of the Ronald Reagan Library.

The Reagan formula framed America's dilemma as a stark choice: on one side, a failed and overliberalized society taken in by subjective complaints of pain and, on the other, a conservative restoration founded on objective criteria for measuring true need. For decades and even centuries, regard for the pain of others and the structure of relief had been an issue for the design of good government and sound civic affairs. Since World War II, the rise of chronic pain had posed a multifaceted challenge with an ideological edge. People in pain came in many forms: soldiers crippled by a series of wars; industrial and service workers coping with work ailments and repetitive labor injuries; the elderly and their ailments, their numbers growing in proportion to the general population. Certainly, liberal social programs like Medicare and Medicaid had encouraged society's increasing sensitivity to the subjective pain of others. Collectively, these trends worried liberals and vexed conservatives alike—from the Eisenhower and Johnson eras through the Nixon and Carter terms.
¹⁹
It was Reagan, however, who framed the issues so dramatically, so starkly, and in such partisan terms that pain became a wedge issue and a litmus test for one's views on crime, fraud, and dependency writ large.

Where gate control theory had been intimately linked to liberalizing the pain field and validating subjective pain as true pain in the late 1960s
into the 1970s, older theories of pain as psychologically illegitimate (common in 1950s psychiatry) reappeared in the 1970s and 1980s to support and echo rising neoconservative sensibilities. Steven Brena, the Atlanta pain clinic director who had introduced the notion of pain as a learned experience (see
chapter 2
), found that his theory resonated with an increasingly conservative populace. In his 1978 book,
Chronic Pain: America's Hidden Epidemic
, he wrote that Western society had “gone too far in passing laws granting monetary compensation for escape from work via pain complaints.” In his own clinic, he had observed “the wisdom of St. Paul's instructions to work for a living.” A life on the dole created “devastating effects of learned sick-behaviors and related feelings of worthlessness” and “trapped [potentially able workers] in a nightmare of welfare lifestyles.”
²⁰

“Chronic pain is often a conditioned socioeconomic disease,” Brena wrote in a May 1981 article. “A majority of chronic pain patients show pain behavior in excess of biomedical findings and disability ratings out of proportion to their actual physical impairment.” Where President Carter and his HEW secretary Califano had made fraud and abuse a central concern, Reagan's HHS secretary Richard Schweiker elevated these types of questions—the medical proof of pain—to a new level.
²¹

For Brena, one mystery of pain was why some people dwelled on their experience while others did not; he used the psychological theory of learned helplessness to explain the disparity. The concept (developed by observing the behavior of animals and people who have no control over their situation or outcomes) proved to be appealing for those worried about the unintended effects of pain relief and even welfare. In situations of chronic distress, Brena asserted, people who fixated on their pain and who had pending disability claims reported higher subjective pains. Even after being medicated, their complaints persisted. By contrast, pain sufferers who did not fixate on their pain and who did not have stakes in the disability system reported lower subjective pain. Simply put, the pain sufferer with no pending disability claim, no spouse on whom to lean for support, and low pain behavior had a better response to medications. This was true for either placebos or analgesics.
²²
Though Brena's formulation was not explicitly political, there is little doubt that this view of learned pain and disability resonated with the rising conservative sensibilities of his time.