Pre-Existing Conditions

Our healthcare system has been broken for a long time. Here are some old thoughts on the same old problems.

Whatever health insurance plan Luigi Mangione was on before, however high his deductible or copayment might have been, whatever grievance he may have had with United Health Care, he is now going to enjoy full medical coverage, subsidized by U.S. taxpayers, for the rest of his life. That’s how broken, and how stupid, our healthcare system is.

Not only that, but the American people have become so numb to the lobbying might of the parasitic medical insurance industry that neither party made healthcare reform much of an issue in the 2024 presidential campaign. Our faith in the Democrats fixing the problem is so flimsy that we voted for a guy who has been promising, for eight fucking years, to produce a better healthcare plan but has yet to do so, and who has vowed, time and time again, to repeal the Affordable Care Act—a popular program which a sizable chunk of our electorate does not realize is the same “Obamacare” that Trump routinely denounces.

Worst of all, it took an assassin’s bullet to bring our clusterfuck of a healthcare system back into the headlines. That’s why Mangione is being embraced in some quarters as a working-class hero. People are not celebrating that he murdered another human being, but that he called the media’s attention to such a life-and-death but largely ignored subject. Consider: right after the UHC CEO was gunned down in Midtown Manhattan, a major healthcare provider, Anthem Blue Cross Blue Shield, decided that, on second thought, its newly-imposed cap on how much anesthesia it would pay for during surgeries was maybe not the greatest idea, and reversed the ghoulish policy. Now that, my friends, is obeying in advance.

None of this stuff, alas, is new: not the incomprehensible failure of Democrats to craft a winning argument for universal coverage, and not the potential for our faulty healthcare system to inspire acts of violence. This has all been going on for years. I know, because I wrote about both topics years ago.

In May of 2012, I published a piece called “Five Arguments for Universal Health Care Democrats Should Be Making.” This was six months before Barack Obama would defeat Mitt Romney and win re-election.

Here’s the first of my proposed arguments:

1. It’s in the Constitution.

It is the job of the president, the Congress, and the Supreme Court to, above all, uphold the charges set forth in the Constitution, which begins thus:

We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.

Where is it written that “provide for the common defence” is limited solely to military engagement? Answer: it isn’t. That’s because the Founders, in their infinite and inviolable wisdom, recognized that domestic tranquility and general welfare might one day be threatened by a force more nefarious than an army of foreign humans.

Although the United States has plenty of enemies against whom we may one day have to make conventional war, the fact is, at this stage of our history, the greatest threat to our national security is a biological, rather than military, foe. An outbreak of smallpox, or some mutant strain of avian flu, is far more likely to wipe us out in mass numbers than a North Korean nuke. Did you see Contagion? That could totally happen.

When a candidate or Congressman says the healthcare system is just fine, thank you, that a single-payer option is socialist, what he’s really saying is, “I’m more interested in enriching my benefactors, the health insurance companies, than upholding the Constitution.”

Fast forward eight years, and the entire country was in lockdown because of covid-19. Trump’s negligent pandemic response wound up killing some 300,000 more Americans than would have died if he took a smarter approach to the outbreak—although some estimates put the number at closer to 600,000. That’s how many died in the Civil War. North Korea? Not so much.

And how, you might ask, did the United States government fight the pandemic? By underwriting the medical research, indemnifying pharmaceutical companies, and absorbing the cost of the vaccines. So I guess we can have federal healthcare when we feel like it. Huh.

Next is an argument I still can’t believe no politician is making:

2. It’s pro-business.

Our current healthcare system is bad for businesses large and small. It’s bad for doctors, it’s bad for patients. The only business it’s good for is the health insurance business. How the GOP, a party that presumes to be pro-business, could support it so staunchly and reflexively baffles the mind.

Founded on the odd mandate that employers should spring for health care, our current system puts a stranglehold on small business, the lifeblood of American innovation and ingenuity. How many would-be entrepreneurs decide not to start up a new business because of concerns about health care expenses? How many existing small businesses are not hiring more workers because of concerns about health care expenses?

And it’s not just small companies. Our current healthcare system almost brought down General Motors, long considered the bluest of blue-chip American companies, and one of the biggest corporations in the country. GM’s near collapse (sidenote: Romney, the Bain Capitalist, would have let it die; Obama, flexing his mighty socialist muscles, saved the auto industry) was not the result of decreased demand for American automobiles. Rising health care costs are what came this close to killing Detroit.

One of the main reasons wages have been essentially flat since I left college in the mid-nineties is that any increase in employee compensation goes directly to covering increased healthcare premiums. Liberated from the shackles of the healthcare mandate, companies would be free to increase salaries and hire more employees. (Also, unwieldy unions, like the Teachers Union, would no longer have to trouble themselves with negotiating healthcare costs during collective bargaining—a win for everyone).

But why would we want that, when noted scholar Sarah Palin insists that universal coverage would bring about “death panels?”

I then wrote about a friend of mine trapped in insurance hell because she has a congenital heart defect called aortic coarctation:

3. It’s non-discriminatory.

. . . I understand the actuarial reasons for an insurer to choose not to get involved with Melanie, or the thousands of Americans with corresponding medical histories who are similarly screwed. But how exactly is this fair? Aortic coarctation is something she was born with, in the same way that other people are born with dark skin. I don’t see how denying Melanie medical coverage because of a congenital heart condition is any different than denying, say, Zadie Smith medical coverage because she’s Black (Zadie Smith, of course, is British, so she never has to worry about this crap).

The fourth argument is basically what Jay Feinman talks about in Delay, Deny, Defend: Why Insurance Companies Don't Pay Claims and What You Can Do About It—although that book is actually about property and casualty insurance, not healthcare:

4. For-profit health insurers operate at cross purposes.

Monthly premiums, co-payments, and deductibles are skyrocketing, which is bad for both individuals and their employers, who in some combination pay the bills. High student loans, ever higher malpractice insurance premiums, and the monopolistic “reasonable and customary” rules imposed by insurance companies mean that providers, too, are suffering. So if the patients are paying more, and the doctors are making less, where is all the money going? To the insurance companies. And therein lies the problem.

For-profit health insurers seek to cover only the relatively healthy, to minimize risk (ask Melanie); keep “reasonable and customary” costs as low as possible, to maximize profits; and require byzantine rules and regulations, to make collecting money—whether you’re a patient or provider—so frustrating that you give up. You can run a health insurance company to generate as much profit as possible, or you can run a health insurance company to provide the best care possible, for the most people, at the lowest cost. What you can’t do is both. Even if you say so on your prospectus.

(This inherent contradiction, incidentally, is unique to health insurance. Life insurance companies never have more than one claim per person, and the only way to beat the system—that is, to get the biggest payoff from the least investment—is to die immediately: not what you or the company want. Homeowners and automotive insurance are volitive; you can choose not to own a home or drive a car. But everybody gets sick sometimes).

And, finally:

5. Government is the solution, not the problem.

You may be an eye doctor, Rand Paul, but you can’t see the truth. The only force big enough to combat the juggernaut that is the health insurance companies is the federal government. Period. In this fight, you’re either with the government (that is, the people) or the corporations (also people, if you think like Mitt). . .

The countries of Europe and Canada have given us plenty of models for universal health care. Here’s another: a quasi-governmental system, modeled on the Fed, owned in part by member health insurers, overseen by a federal appointee, answerable to Congress. I’m sure there are others. (And if you ever find yourself arguing for the current system on the grounds that emergency rooms are prohibited by law from denying medical treatment, I shall direct you to my brother, who works in the ER, or any of his colleagues, who will explain how inefficient and dunderheaded that policy is).

We can find a solution, but only if both sides are willing to do so; the first step is admitting we have a problem. Obamacare—or Romneycare, if you will—is a step in the right direction, but not a solution to the larger issue: no one, individual or shareholder, should profit by denying medical help to the sick.

You’re not gonna believe this, but the architects of Project 2025 don’t agree with the part about government not being a problem. Things are going to get worse before they get better.

Again: I wrote that well over a decade ago.

In June 2017, with Republicans poised to pass a particularly cruel healthcare bill, I fretted that a Luigi Mangione may imminently become so frustrated by the heartless healthcare system that he would take up arms against a sea of denied claims. In “Germs, Guns & Trumpcare: With Cruel Health Bill, GOP is Playing with Fire,” I wrote:

It’s one thing to cut services that GOP core voters hate anyway to save some coin for the wealthy and corporations; quite another to, in effect, condemn millions of people to bankruptcy and death to achieve the same result. I don’t think Mitch McConnell and his minions realize how ugly this could get.

In the time between writing the first and second drafts of this piece, a disgruntled man translated his political grievances into actual violence, gunning down a member of Congress. The shooter, as the conservative press is so keen to point out, is a member of the “alt-left.” The Congressman he attempted to kill, Steve Scalise, is a hard-right Republican—a Second Amendment purist who once described himself as “David Duke without the baggage.” I can’t pretend to know what went on in the head of James Hodgkinson, who is certainly no hero, but the Congressman’s racist, homophobic policy positions likely made Scalise a target.

Republicans appeared shocked that this tragedy happened—Paul Ryan actually demonstrated empathy, an emotion I did not think him capable of feeling—but really, if you sow hate, you should not be shocked when hate is reaped. The GOP is terrified of dissent. Its president vets who attends his rallies. Its members of Congress refuse to hold town halls. Its Senate majority leader instructed Capitol police to remove peaceful protesters in wheelchairs. When the usual avenues for protest are closed off, then what? Do they really think the people will give up and go home?

To the contrary: if the Senate passes this egregious tax break for the wealthy/ corporations masquerading as a healthcare bill—and it’s increasingly, alarmingly likely that it will—James Hodgkinson may well become, unfortunately, not a deranged lone wolf but a template for a desperate form of last-resort resistance: the John Brown of the 21st century. . .

To state the obvious and the obligatory: I do not condone violence. I don’t want anyone to get hurt. I’m not calling for an armed insurgency against the GOP agents of destruction. But Republicans have been in a pathological state of delusion for a long time now. They can convince themselves that Donald Trump is competent, that his cabinet members are exemplary, that Russian collusion and global warming are hoaxes, that Obama is a Kenyan Muslim, that every questionable move made by any GOP member can be explained away by something untoward Bill Clinton once did. But this can only go on for so long. The alternative facts will stop working when the unpaid medical bills, house liens, wage garnishments, and bankruptcy filings tell a different, grimmer tale.

If this bill passes—and brainwashed GOP voters come to understand exactly what was taken away from them, and for what deplorable reason—Republican lawmakers shouldn’t be surprised when their wake-up call takes the lamentably violent form of a hundred James Hodgkinsons, locked and loaded…when the targets on their backs become something other than figurative.

That’s right: I predicted the rise of political assassinations for reasons of our broken healthcare system—not because I am some Nostradamus, but because, absent meaningful change, that outcome was, sadly, inevitable. Vigilantism is the hallmark of a failed state.

Here we are, seven and a half years later. What the MAGA GOP plans to inflict on the country next year will be orders of magnitude worse than what I was writing about in 2017. I am very, very concerned that Luigi Mangione has started a trend; the generally positive social media response to his brutal act has only heightened my worry.

To state the obvious: this is not how we want to live. This is a red line we never, as a society, want to cross. Violence is not, and can never be, the answer. We have been very, very fortunate, in a country armed to the gills, that political assassinations have not become a thing.

The way to prevent further acts of violence from happening is not to give group therapy to terrified CEOs; it’s to actually, you know, fix the problem.

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