Our Healthcare System, a Reign of Terror

the question is not "was this act good?," the question is "why is your moral judgment only activated for certain kinds of victims?"

I’ve been getting a lot of “DO YOU DENOUNCE LUIGI MANGIONE?” emails lately. As the grandchild of someone who was specifically targeted during the worst excesses of the Red Scare - as in, his name was literally in the bills - I decline all demands to take a loyalty oath or pass a purity check. Sorry. It’s just not in my nature to give you that.

There’s a phenomenon where I articulate an argument that people like when I target the “right” people and not when I target the “wrong” people. Here’s is a good example: the uselessness and emptiness of judgment as a political force. I’ve written about this in regards to the social justice movement many times; the woke set just cannot stop believing that their judgment in and of itself somehow has political force, somehow matters. They appear to be convinced that if they just judge hard enough, that judgment will somehow be given material force, somehow actually create change. This misguided thinking is the result of a number of factors, principle among them that the people who believe in those politics tend to be those who have always been governed by authority figures who they can appeal to and secure some semblance of justice, Mommy and Daddy or the teacher or the RA or some other figure in charge who makes the world make sense. Judgment is a step in politics but a rather incidental and trivial one, and it matters only insofar as it leads to coalition building and eventual victory. That Mangione’s act is not a step towards a better and more humane American system is acknowledged by everyone, including, it seems, Luigi Mangione. To ask, as so many aggressively did, whether I “really think” this gets us closer to Medicare for All is thus a non sequitur. It’s got nothing to do with anything I’ve ever said.

DO I DENOUNCE LUIGI MANGIONE? I’m not out here showily condoning him, if you’re desperate for that information. I’m opposed to the death penalty, which is a bit of actually-meaningful ethical information about me. But under precisely the same reasoning that many of you celebrated when I used it to ding social justice politics, I understand that my judgment of Luigi Mangione is meaningless, useless. Condone or condemn, it makes no difference. The target is dead. The shooter is going to jail for the rest of his life. He has no movement or party. Despite what a hundred breathless dispatches from the Sensible Center are telling you, AOC and Bernie Sanders aren’t saying kaddish for Luigi’s future on the floor of Congress. This moment is being represented as a frenzy for the left, but in fact the people who are frenzied are our old friends in the tongue-clucking center-left, the fainting couch crowd. The average columnist for The Atlantic - hell, for The Nation - is someone who is much, much happier attacking the left for its supposed extremity than they are criticizing the right for anything at all.

And as someone who is plugged in to a lot of lefty networks, I see very very little in the way of explicit political justification for the killing. What most people are saying, in the realm of politics, is that a broken and cruel medical system is going to make people do crazy things; that the incident has helped reveal vast stores of discontent and rage towards that system among Americans, and not at all confined to lefties; and that the actually socially-relevant issues at hand now are much larger than this murder. Yes, he’s become a folk hero. But as Michelle Goldberg wisely notes, folk heroes are an “is” phenomenon, not an “ought” phenomenon. Should’s got nothing to do with it. And the fact that most establishment types are able to summon operatic compassion for the murdered CEO, but view those killed by our healthcare system only through an actuarial table, brings us to Mark Twain.

Twain’s statement above is taken from his novel A Connecticut Yankee in King Arthur’s Court. That book shares a status with Gulliver’s Travels and Animal Farm and several others in that it’s primarily a satirical work now read by modern readers who almost all miss the satire but who still really enjoy the yarn. I haven’t read it since I was a teenager, so it’s particular placement in the text is a bit of a mystery to me now. But no matter. That paragraph is, to me, both an efficient summation of an essential element of left-wing theory and yet also not particularly ideological at all. The message is as simple as it appears: it is logically and morally bizarre that historical crimes, like some of the conduct in the French Revolution, evoke our continuing indignation, while the horrible conditions that inspired those acts don’t, even though they killed far more people. The number of innocent people mistreated, impoverished, starved, and killed thanks to the system imposed by the French monarchy, in the century before the first revolution, amounts to an injustice that absolutely dwarfs the combined evils of the Reign of Terror. And yet people still write big-think nonfiction books about the horrors of the revolution in which that far larger pile of bodies is referenced glancingly, if at all. People hit their heads and go to the hospital but decline to be scanned when they learn how much it’s going to cost them, then they go home, go to sleep, and never wake up because they had a brain bleed they couldn’t afford to have diagnosed. Stuff like that happens absolutely all the time. And each of those people are just as loved by their families as the United CEO. The vast silence our culture reserves for their fate demonstrates moral incoherence.

I say that this passage efficiently expresses fundamental left-wing perspectives because the left must constantly fight for public recognition of the unnecessary suffering and injustice brought on by The Way Things Work. I say that it’s not even ideological because Twain’s perspective is so eminently sensible; it’s nothing more than an assertion that moral logic should make sense, that the way average people respond to different kinds of suffering and death can’t be reconciled in any kind of comprehensible moral system. My comments here will light up with people saying that the Terror was made up of acts committed by people, decisions that were made, active choices, and the hunger and poverty and oppression weren’t chosen by anybody. But of course the monarchy and nobility were built by people making choices. Feudalism was built by people making choices. The French system was defended long after its fundamental evil was obvious, and that defense was mounted by people, making choices. So too with our healthcare system; it did not emerge ex nihilo but was built by profiteers who wanted to extract as much money as they could from sick people and is now defended by those who would like to go on extracting as much money as possible from sick people. Protected though they may be by many layers of bureaucracy and distributed culpability and a healthy dose of The Way Things Work, many are making individual choices that kill within that system. The question “Should a lone gunman kill CEOs?” is not a societally meaningful one; you will not find an establishment politician who will answer in the affirmative. “Why do we permit ‘death by slow fire at the stake’?” most certainly is a meaningful question.

Derek Thompson had an economist on his podcast and he defended the health insurance companies as mere cogs in an unhealthy system, saying that we don’t, as good economists, judge private companies for “profit maximization.” Of course, profit maximization results in things like a young woman being denied coverage for $8,000/month life-saving medication by her insurance company, leaving her totally powerless; that’s the sort of thing the insurance companies do every single day. A tenacious Penn State student had ulcerative colitis and, despite the fact that he and the university had paid their fair negotiated share in good faith, UnitedHealthCare denied him access to desperately-needed treatment. In their investigation into his story, ProPublica learned that executives there had openly laughed at him and mocked his efforts to actually use the health insurance he had paid into. When people die this way, that’s the murder wrought in heartless cold blood. And if the wonk types want to insist that we can’t morally judge the insurance companies for acting that way, that again is an example of decisions that we conveniently deny are decisions. That’s ideology. That’s the best interest of a particular economic class, expressed in choices that the powerful decide are not choices. But they are choices, and they invoke Twain’s undeniably powerful question: why should they be exempt from the same exact moral revulsion that people feel towards the murder wrought in hot passion?

Thank you, Obama, for bringing us a system where the working poor can choose a healthcare plan online that demands they pay a deductible of 3%, 4%, 5%, 6%, 7% of their gross income before they actually get any coverage, ensuring that they’ll never get any value from what they pay at all! Thank you Heritage Foundation!

Libertarians are all about opposition to coercion. Nobody’s forcing you to work in dangerous, exploitative, and demeaning workplaces! In a market system, you can do what you want. You’re free! But of course, if you have to work to eat and you have to eat to live then you have to work or die, and even those libertarians will tell you that putting a gun up to someone’s head and telling them to do what you want isn’t an exercise in freedom. The gun, I’m afraid, is always at our head if we have to eat to live, or to take medicine to live, and on and on. That’s where the “but that’s just reality!” stuff comes in. They pretend that the universe invented capitalism so that nobody can criticize it. That’s how you get to Yglesias Land, where there is no problem markets can’t fix, and if markets can’t fix a problem, we’re not allowed to call it a problem at all. But the fact that we have insisted that access to food must be restricted to those who can buy it in a market is a choice. That’s a decision, a human decision. It’s not nature. It’s not the hand of God. It’s a human choice with real and vast moral consequences. And the people who defend that system have their hands on the trigger. That’s just a fact.

Consider Ross Douthat’s capacious sympathy for the UnitedHealthcare CEO. That he feels that compassion is not a problem for me, and again, I think if you actually try to engage with what people are saying rather than to justify your preexisting culture war attitudes, you’ll find very few people of prominence on the left who are out there insisting that no one should feel human sympathy for the guy. The question, again, is who don’t you feel sympathy for, and why? Leave healthcare aside for a minute and consider other parts of the Second Terror, that lifelong death from hunger, cold, insult, cruelty, and heart-break. The kind of person who rides the subway day after day, brain addled by mental disease, emaciated and hungry, falling through the cracks of both conservative carceral politics and liberal do-goodism, sentenced by an indifferent judicial system to a program that could have saved his life, if that system bothered to enforce that sentence, was willing to lock the door. Douthat is a Christian; it’s hard to imagine someone more emblematic of the kind of person that Christ compelled us to care about than Jordan Neely. And yet….

I have already said what I need to say about Neely, and I still believe that the most important lesson to take from his story is that the structural resistance to involuntary commitment that liberals have inculcated is unspeakably cruel, that it kills. (Had the ward he was confined to by judge’s act been locked, he would be alive today; he lost his life for the price of a deadbolt, thanks to “disability activists.”) It remains the case that Daniel Penny did not need to kill him, and I wanted him convicted on at least some charge. Of course, conservatism being the home of moral lepers, Penny has been made into a folk hero who is celebrated with none of the complications or provisos or scolding that attends the lionization of Mangione. They make memes with Derek Chauvin driving his knee into Neely’s neck; I saw a screengrab of a video game where you press A to choke him to death. Neely was, indeed, serially violent, and against senior citizens to boot. That is just to say that actual severe mental illness is inherently ugly, cannot be cured with yoga, frequently provokes real violence, and the way decent people have drained it of any negative valence does nothing at all for the mentally ill. Neely was also one of society’s great victims as well as an aggressor, a person utterly unable to secure his own basic material survival, born poor, disturbed since early adolescence, emotionally dysregulated even before his murdered mother was found stuffed into a suitcase. The world handed him synthetic marijuana and easily-jumped subway turnstiles for his trouble. This would seem to be a good opportunity for conservatives to show that they can embrace law and order and advocate for someone like Penny while still finding some basic sadness over Neely’s death - but, well, they can’t. Because American conservatism isn’t a political movement, it’s a social club for shivering cretins.

I am trapped between liberals who summon compassion for Jordan Neely by lying about just how deeply broken he was and conservatives who refuse to summon compassion for him at all.

Either way, in Jordan Neely we truly see “that unspeakably bitter and awful Terror which none of us has been taught to see in its vastness or pity as it deserves,” a man who suffered as the thief on the cross suffered. Yet Douthat has not expressed any concern over Neely at all, none. Nor has Andrew Sullivan, another of our more prominent conservative Catholic writers. If only Neely had been a fetus. Why this silence? Well, I suppose the reason is that even those conservatives who work diligently to stay out of the MAGA fray can’t help but find themselves more animated by the shocking death of one CEO than by the endless drip-drip-drip of Jordan Neelys, helpless people trapped in a merciless system built by human choice and meant to serve the interests of only some humans. Conservatism, by its nature, cannot comprehend the Second Terror, cannot name it, must not name it. Because if conservatives could bring themselves to care about the coffins filled by that older and real Terror… well, they wouldn’t be conservatives at all. For Ross and Andrew specifically, about Jordan Neely specifically, I would only remind them of their bible’s most indispensable verse: that which you do to the least of my brothers, you do unto me. Your Christ has a place for him or he doesn’t. It’s up to you.

Since I was went public as someone with a serious mental illness, I have on a handful of occasions been asked to help with someone’s deteriorating partner or sibling or friend, to talk to someone dealing with a dangerous mental health episode or their loved ones and provide advice and encouragement for getting into care. Doesn’t happen often, but has happened often enough. It’s tough sledding. I don’t have any particular wisdom to share, I’m afraid, and the homespun kind you find in far too many mental illness memoirs is always fugazi. Besides, what works with one person doesn’t work on another. Ultimately those of us engaged in the effort to save someone’s life when they’re wracked with psychosis are helped most by the fact that psychotic people are, in some deep sense, desperately tired and looking for an excuse to give up. Unfortunately, as I said above, 60ish years of mental health libertarianism, smuggled in under the cover of “compassion” and the hippie movement, has made it far more difficult to ensure emergency psychiatric care than it should be. The good news is that, if there’s a genuinely motivated loved one and a patient who is not so far gone that they’re violent in the immediate term, you can usually convinced them to at least be evaluated. Keeping them in care is another story. Still, you often can get someone to agree to go see a psychiatrist, even someone very sick.

But, you see, thanks to our incredibly rotten system that’s only the first part, often the easier challenge. The next part is finding care for them so that they don’t bankrupt themselves, don’t ruin their post-psychosis life. If somebody’s an immediate danger to themselves and to others, well, you just get them to a hospital where a doctor will introduce them to Haldol and let the chips fall. But that’s not most patients. (This is a whole big ugly hard sad story, the mostly-psychotic-but-capable-of-decision-making story.) Most patients want help but are desperately afraid of taking on crippling medical debt. And after convincing a deeply sick person to seek care, and then sitting there watching them try to get it in our broken system… well, it’s as hopeless and heartbreaking a feeling as I’m aware of, and I watched both my parents die of cancer when I was a child. I’m sorry if that sounds like a cheap reference to personal trauma to you but I’m struggling to summon the words to make you understand what it feels like when you’ve successfully wrestled with a psychotic person for long enough that they’re willing to go get medical care and they can’t because the richest nation in the history of the world isn’t willing to give it to them.

The sad fact is that a majority of psychiatrists don’t take Medicaid at all. Point blank, they refuse to treat poor people. Why is this legal? How is it that no one’s dragged them into the streets to defend that cruel decision? I have no idea. But it gets worse! A shockingly high percentage of psychiatrists don’t take insurance at all. Why would you make that choice, if you’re a psychiatrist? How is that in your best interest, to preemptively reject a vast majority of potential customers? Because by taking only patients who can pay cash, you eliminate all of the actually-hard cases. You sidestep the fundamental work of psychiatry, juke the real labor. You never have to deal with genuine illness. You get to enjoy a dainty life handing out Vyvanse to children whose parents want them pharmacologically pacified and doling out Ativan to bored housewives. A majority of American counties have no prescribing psychiatrists at all, for the record. So you go into your insurance companies automated system and you look in vain for someone who’ll treat your debilitating illness…. I wouldn’t wish it on my worst enemy.

Here in true blue Connecticut, one of the country’s richest states and one of its most generous with its social safety net, Medicaid is referred to as HUSKY Health. I take it that this euphemism meant to make using it less stigmatizing than telling a doctor’s office you have Medicaid. Thanks to more-or-less random chance, many times in my life I’ve sat by, mute and impotent, listening to a person who badly needs healthcare say into the phone “I have HUSKY,” then felt them slump in defeat when yet another receptionist has told them, sorry!, we don’t treat poor people here! This is a business, and it’s not good business to take part in our country’s stumbling, basic, half-hearted efforts to ensure that poor people can actually access medical care.

And the way that all makes me feel - well, it makes me want to kill someone.