[ Our current system defines health as the ability to work. Those
who can’t are abandoned and exploited. If you’re too sick to work,
you will be forced into poverty twice over: First by the loss of
wages, and second, if lucky, by SSDI, or poverty.]
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THE CATASTROPHE OF AMERICAN HEALTH CARE  
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Abby Cartus
February 23, 2023
Abby Cartus
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_ Our current system defines health as the ability to work. Those who
can’t are abandoned and exploited. If you’re too sick to work, you
will be forced into poverty twice over: First by the loss of wages,
and second, if lucky, by SSDI, or poverty. _

Assisted living facilities are being pressed to address the growing
needs of older, sicker residents., Kaiser Health News

 

I never went to Dixmont, though lots of my high school classmates and
friends did. My parents mildly discouraged me from venturing up into
the thickly wooded hills where it sat, not because kids went there to
drink and smoke and scare each other (which they did) but because the
dilapidated buildings were full of friable asbestos and the
underground tunnels were probably even more structurally unsound than
the buildings. The property, at the time I was a teenager, had been
essentially abandoned for more than a decade.

Dixmont was named after Dorothea Dix, the nurse and reformer whose
lobbying efforts were instrumental in creating the asylum system in
the United States. The asylum movement, originating in the 1840s,
aimed to improve the treatment of people with mental illnesses, who
were typically subject to a litany of esoteric forms of abuse and
neglect including, but not limited to, exorcism, bloodletting, and
warehousing in jails. Dix, who worked in a jail as an English teacher,
was shocked by the conditions that psychiatric patients were subjected
to and made it her life’s work to advocate for more humane
treatment. She spent decades campaigning for state governments to open
asylums, and in this she was successful. Dixmont State Hospital in
Kilbuck Township, Pennsylvania—roughly 12 miles up the Ohio River
from downtown Pittsburgh—was one of the fruits of her labors. At its
peak, the hospital held more than 1,000 patients in therapeutic
incarceration on its (originally) state-of-the-art campus including
several buildings, manicured grounds, and even its own cemetery.

The reform movements that created the asylum system produced a myriad
of new problems, cruelties, and abuses in an attempt to address the
old ones. Dixmont, like other institutions around the country, came to
embrace the disquieting practices of mid-century psychiatry, with the
extensive use of restraints (including, when it became available, the
use of the antipsychotic drug Thorazine as a “chemical”
restraint), hydrotherapy (worse than it sounds), and electroshock. By
the 1970s, Dixmont was in financial trouble, and in 1984 it was
finally closed for good. The buildings were demolished years later,
and all that remains today is the overgrown Dixmont cemetery, where
patients were buried after they died in the hospital.

Why and how would a reform movement dedicated to improving treatment,
and to treating psychiatric patients humanely and with dignity, result
in something like a Willowbrook
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a Danvers
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A recent book by Beatrice Adler-Bolton and Artie Vierkant, _Health
Communism_ [[link removed]]_,_ suggests an
answer: The asylum movement operated by, through, and according to the
logic of surplus. The authors propose that, in capitalist societies,
the distinction between a productive worker and an
unproductive _surplus_ drain on the public is at the heart of
contemporary notions of sickness and health. The authors argue that
this dividing line between worker and surplus is imaginary—and
consequently that “health” is not the individual physiological
state that we are accustomed to thinking of as a private property
right. Rather, they argue, what we call health comes down to the
capacity to perform waged work, to sustain oneself without help or
public expenditure. Though the division between worker and surplus is
imaginary, it is an ongoing process of negotiation and certification
with real effects. The division is enforced not only by institutions
like Dixmont but by the entire structure of contemporary health care.

The economic valuation of life is at the root of the variety of ills
enacted by and through the health care system. Contemporary
preoccupations with cost containment, the “overconsumption” of
health care, and the ideological preference for “cost-sharing” or
making individuals bear part or all of the “costs” of their care
all flow from the economic valuation of life. This, per Adler-Bolton
and Vierkant, is why the logic of health insurance in the United
States relies (and must rely, stubbornly and in the face of widespread
and well-known inefficiencies) on rationing and means-testing care
provision. Rationing occurs first and foremost by employment
status—50 percent of Americans have employer-sponsored health
insurance—but also through notoriously opaque and uneven prices,
ability to pay, and the variety of profit-seeking tactics insurance
companies and hospital systems pursue, such as prior authorizations
for certain procedures or medications.

If you’re too sick to work, you will be forced into poverty twice
over: First by the loss of wages, and second, by the grueling process
of securing Social Security Disability Insurance.

If you’re too sick to work, you will be forced into poverty twice
over: First by the loss of wages, and second, if you’re lucky, by
the grueling process of securing Social Security Disability Insurance,
or SSDI (a process Adler-Bolton has been through). Eligibility for
SSDI is determined via strict federal determination of a qualifying
disability _and_ accrual of enough “work credits” to receive the
income support payments. Supplemental Security Income, or SSI,
strictly limits the assets or nonwork income that a beneficiary may
have: Individual recipients may not have more than $2000 in so-called
countable assets, including money in savings accounts, and to have an
asset (like a piece of jewelry) exempted from the limit involves a
byzantine process of actuarial determination (jewelry may be exempted
if the individual can establish that they wear it
regularly _or_ that it holds sentimental significance). SSDI does
not place limits on these assets, but does limit the income
beneficiaries may earn through work.

The reality is that even if a person can access the SSDI
benefit—Adler-Bolton and Vierkant refer to the typically
two-year-or-longer application process as the “death window” for
the number of people who perish waiting for their benefits to be
approved—they will be subject to periodic federal reviews of their
medical status to determine that they are still disabled and severely
restricted in their ability to earn money above and beyond the low
payments. The logic underpinning SSDI is that a person who is able to
earn sufficient income through work is not disabled. The ability to
work is how the bureaucratic state distinguishes the truly sick from
the truly healthy; the equivalence of health with productivity
determines how miserly public benefits are rationed and distributed. 

Institutionalization, the process that filled asylums like Dixmont,
and deinstitutionalization, the process that emptied them, are also
related to the economic valuation of life. Both institutionalization
and deinstitutionalization furnish examples of one of the central
concepts of _Health Communism, _what Adler-Bolton and Vierkant term
“extractive abandonment.” (_Health Communism_ is strongly
influenced by Ruth Wilson Gilmore’s 2007 abolitionist
classic _Golden Gulag_
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off from her term “organized abandonment.”) Extractive abandonment
describes how unproductive “surplus” populations are not just
abandoned politically (and warehoused in a prison, asylum, or nursing
home, for example) but are also exploited, as corporations and other
private interests extract whatever profits they can wring from them or
their care and maintenance.

The several distinct waves of deinstitutionalization, beginning around
the 1950s, were in part a response to the widespread institutional
abuses exposed by journalists and advocates. Yet
deinstitutionalization did not always return psychiatric patients to
community living, and rarely accomplished their seamless integration
into community life. Instead, as the authors write,
deinstitutionalization generally “redistributed the asylum’s
responsibilities into a vast, chaotic network of public and private
entities” like nursing homes and general hospitals.

The causes of this shift were political-economic as much as they were
moral. Medicare and Medicaid, the safety-net health insurance programs
in effect from 1966, were powerful drivers of deinstitutionalization.
Medicaid, for example, covered psychiatric services provided in
hospital settings, but not the same services provided in state-run
psychiatric hospitals. This state preference for private, non-asylum
care built into Medicaid (and probably motivated by the horrific
reputation of state asylums, in addition to capitalistic ideology)
precipitated rapid growth of acute care beds for psychiatric patients
in general hospitals. The effect was to essentially privatize
psychiatric care, folding it into the private health care and
specifically the hospital system. Partially as a result of this,
mental and behavioral care are, today, some of the most inaccessible
health services. (Another brief example: since states split Medicaid
costs with the federal government, states could save money by moving
patients from 100 percent state-funded institutions into private,
for-profit nursing homes, for which the federal government will match
the state’s Medicaid contribution.) The incentives of Medicare and
Medicaid funneled people in need of psychiatric care into general
hospitals where their treatment generates profits for the hospital
system, all while imposing costs on sick individuals.
 

The worker–surplus dividing line is permeable—people cross it
whether they want to or not. Today’s workers are tomorrow’s
surplus, and vice versa. The political economy of capitalism, not
biological destiny, yoked the concept of health to economic
productivity. As just one example, American psychiatry facilitated a
long process of surplus-making over a period of a century, consigning
people to lonely life terms in state asylums on the basis of shifting,
historically contingent diagnostic criteria.

ESSENTIAL WORKERS ARE EXPLOITED AS USUAL, AND ABANDONED TO CONSTANT
EXPOSURE TO POTENTIALLY DEBILITATING OR LETHAL HARM.

What’s more—someone (anyone) can be both worker and surplus at the
same time. Until 2020, “essential worker” was an obscure
administrative term that the Department of Homeland Security used to
refer to workers in sectors and occupations (like health care or the
power grid) crucial to national public health and safety. At the
beginning of the pandemic, for a brief moment of unity, these workers
were celebrated for their bravery and resilience as they showed up to
extremely hazardous jobs with very little protection. Quickly and in
tempo with the relentless march of Covid normalization, this term came
to encompass anyone who could be impelled (either by administrative
fiat or economic desperation) to resume in-person work, who didn’t
have the economic or political power to work from home—that is to
say, working-class people. Many epidemiological investigations
conducted since the start of the pandemic confirm that working-class
people have suffered and died disproportionately.      

The work—of intubating patients, cleaning hospital rooms, delivering
packages, stocking shelves, waiting tables, and staffing hotels so
that organizations that booked in-person conferences pre-2020 don’t
lose huge amounts of money—is so essential that it must not go
undone. The workers, however, are treated curiously like surplus in
the context of unchecked viral spread: exploited as
usual, _and_ abandoned to constant exposure to potentially
debilitating or lethal harm. As Adler-Bolton and Vierkant argue, and
many have said—in the world post-2020, we are all surplus. This
realization has explosive political potential in that the very
necessity of surplus populations to industrial capitalism carries
within it both the threat and promise of refusal.

This revolutionary potential is treated in the latter chapters
of _Health Communism,_ which are devoted to one of the first and
most comprehensive English-language accounts of the radical German
patients’ group _Sozialistisches Patientenkollektiv, _or SPK. The
work of SPK is the other major influence on _Health Communism_ in
both theory (“under capitalism, not all of us are sick, but none of
us are well”) and practice. The title alone of the SPK
pamphlet _Aus der Krankheit eine Waffe machen_ (“make illness into
a weapon”) neatly encapsulates the core argument and core purpose
of _Health Communism. _The carpal tunnel and high blood pressure of
an office worker, the missing limbs and eyes of a steelworker, the
administrative and financial burdens of seeking mental health
treatment, or the constellation of long-Covid symptoms affecting
people from all walks of life are all evidence that, as literary
critic Terry Eagleton has put it, “capitalism plunders the
sensuality of the body.”      

They also demarcate a class—the surplus class—with the collective
power to create serious political problems and opportunities that, for
example, the Biden administration has not reckoned with. Experiencing
symptoms of long Covid is a problem for individual people; four
million people unable to work because of symptoms of long Covid is a
political and economic crisis for the government, whichever party
holds it.

Mapping the connections between health, debility, and sickness is akin
to a consciousness-raising activity, crucial to building the type of
solidarity it will take to realize Adler-Bolton and Vierkant’s goal
of “all care for all people.” _Health Communism_ is, most
fundamentally, a call for a new and expansive concept of health as a
commons, a collective experience, and a collective commitment to human
flourishing, freed from the ideological and financial strictures of
market discipline.

In 1999, 15 years after it closed, the Dixmont property was acquired
by a private family partnership. In 2005, that partnership sold the
property to developers, with plans to turn the site into a shopping
center with a Walmart Supercenter as the anchor. By the following
year, the buildings had been demolished in preparation for the
redevelopment and then, two years later, the hillside on which the
property sits shrugged up and gave way in a massive landslide that
temporarily covered the highway below. Walmart abandoned the plans,
suing the other developers to try to recover some of its costs on its
way out. All that remains today is a fenced-off section of denuded
hillside, and the Dixmont cemetery.

_[ABBY CARTUS is a postdoctoral research associate with the People,
Place, and Health Collective at Brown University School of Public
Health, where her work focuses on overdose prevention, perinatal
epidemiology, and statistical methods.]_

* Healthcare
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* medical care
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* assisted living
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* eldercare
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* elder care industry
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* Seniors
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* senior health
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* health insurance
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* Medicare for All
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* Culture
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* health
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* capitalism
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* critical mass
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* Sickness
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* poverty
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