Medicaid and the "Able-Bodied Man" (Tinged with the Lens of Mental Health)

 First of all, there aren't nearly as many as politicians on the right imply. Unless you live in a state that has expanded Medicaid, most "able bodied men" who get Medicaid benefits are either unemployable because of a disability of some kind or employed but still too poor to afford insurance, even on the "market" created by the Affordable Care Act. Weakening the ACA's expansion provision without completely axing a popular program is, I believe, the real reason Republicans are proposing "reform"; it has nothing to do with fraud, abuse, or the exploitation of the program by a massive but silent cabal of "able bodied men."

As someone who worked alongside the public mental health system for seven years in a non-expansion state, I do have a few thoughts on the matter of reform, though.

The "able bodied men" I worked with, almost to a man, wanted to work. Work is an incredibly important part of the male self-image in America, especially acute in the plains, south, and the midwest, states as "Red" as they come. But mental health disabilities, while often not precluding work, still create tremendous levels of discrimination by employers (100% of the time, in my experience), despite the existence of the Americans with Disabilities Act. The ADA, while a potentially powerful tool, essentially requires someone to self-disclose a disability, opening them up to being denied employment on other pretexts. In the mental health field in particular, men are encouraged to accept disability and disabled identities, to parrot back to providers their diagnoses as fundamental parts of themselves. It was routine to be introduced to someone by name and diagnosis, even though the work I was called to do was ostensibly based on recovery and moving beyond being identified as an illness.

By accepting the life of a mental patient, benefits and services—many of them quite helpful and valuable, such as housing and therapies—would be available to our ostensible "able bodied men." But this access also came with lifelong limitations, both from the system itself (more on those later) and within the minds of the men in the system. Despite wanting to work, these men often don't feel worthy of it, much less capable.

Once in the mental health system, 100% of them also become medicated. While many find these medications helpful, the meds often come with devastating side effects: lethargy; obesity; tardive dyskinesia, which weakens muscles and creates Parkinson's-like tremors. These medications can make the kind of work often open to those who want to work their way off the system, generally entry-level and labor intensive, all but impossible. And even if an "able bodied man" were to convince his service providers that he should seek alternative treatments, there are no guides for stepping down from psych meds, resulting in withdrawal syndromes that are often worse than the symptoms that led to the psychiatric diagnosis to begin with. Especially in rural areas, alternative therapies, such as talk therapies, are difficult to access or unavailable, so our supposed "able bodied man" is out of luck if he both wants help for his mental health challenges and an able body.

More generally, the entry-level work already mentioned that is available to those on Medicaid doesn't come with health insurance, doesn't pay well enough to purchase insurance via the ADA, is part time, and is dangerous or physically demanding. Kicking "able bodied men" off Medicaid will simply leave many of them impoverished, ill, and injured. With no other recourse, they will end up with unstable housing, inadequate nutrition, and frequent visits to the ER. This would shift costs from the public and onto private insurers, as these once "able bodied men" show up at hospitals with a mission to serve everyone regardless of ability to pay, therefore passing those costs along to those of us with private insurance coverage.

Thus an expensive public program becomes an even more expensive public problem, paid through ever-increasing health insurance costs for employers and the employees who qualify for benefits. Chances are that most Republican lawmakers haven't considered this, but it's possible many have but figure that the middle classes have just gotten used to paying more for insurance every year and won't make the connection to the Medicaid cuts they propose.

If we want to actually solve the problem, we should mandate a living wage and vastly expand Medicaid (or more properly Medicare, which, while flawed, is a much better system) to include everyone, much like every other industrialized nation has done. But, since obvious solutions are also politically radioactive in these United States, we could try these half-measures instead:

1. Emphasize preventative care. Private insurers are already starting to do this (though often poorly). While he is dreadfully wrong on many of the details, RFK, Jr. is right about this in the broad strokes. The system should pay out/subsidize prescriptions for nutritious foods, for example, which are often out of reach for those poor enough to qualify for Medicaid. Likewise for gym memberships, exercise equipment, and vouchers for safe and healthy housing. We're perpetuating the problem into infinity when kids of families that receive Medicaid are exposed to lead—whether that's through exposure to old paint or directly injected through the barrel of a gun.

2. Coordinate with other healthy living initiatives (and restore the ones the Trump administration has already killed). If we want to save public money in the long run, we need to spend it now cleaning up neighborhoods (and on lead abatement, as above), creating walkable cities, providing medical transportation in rural areas, and subsidizing neighborhood gardens.

3. Provide evidence-based alternative treatments. Plenty of talk and behavioral therapies have good evidence to back them, such as DBT, CBT, and exposure therapy (for PTSD). They're expensive at first but cheap in the long run. I'd rather pay for someone's equine therapy than see them debilitated by TD, if it comes to that. It makes little sense to have an environmentally damaging "all of the above" strategy for energy policies while not having a potentially helpful one for health care. Further, having more options is synergistic: better physical health leads to better mental health and makes people more employable, more "able bodied."

4. Create greater flexibility. Because so few entry level jobs provide benefits and are often hard on the bodies that do them, one should not have to face the binary choice of employment or benefits. A system designed to graduate benefit levels depending on income, availability of viable options on the ACA marketplace, and the healthcare needs of the individual could go a long way towards the every-"able bodied man"-employed vision of the political right.

The idea here goes beyond a safety net: if we want "able bodied men" to get off Medicaid and to "get back to work," we need a much more solid foundation from which they can launch.

On the Minor Pleasures of Being a Grind

by Lael Ewy

Being neither talented nor smart, my ambitions, modest to begin with and blunted by decades of failure and disappointment, have pushed me into becoming a grind. Where others seem to take to reading or writing or math, to some sport or another, I have always had to work twice as hard for half their success. The only difference between me and those who fall behind has been the willingness to put in the work.

I say ambition, but as much it has been fear, a terror of the abjection of failure, a fear, in my case, based on hard experience. This terror often took the form of compulsion, but since that compulsion was applied to acceptable pursuits—such as academic work—it was largely overlooked by those whose joy it would have been to medicate my striving away. Played out over years, these compulsions have just become who I am, a grind.

I wake up and grind out some (generally ineffectual) exercise, grind out lesson plans, grind out graded papers. I grind out mediocre pieces of writing like this one, fueled by thousands of hours of reading because, no matter how many hours I have in, I still read slowly.

At best, I also read deliberately, not missing the nuance, maybe even forming better questions along the way. I'd like to think I feel with James Joyce, though I might be less likely to understand him as others do. I know that Emily Dickinson and I, at least in short bursts, look out at Amherst through the same set of eyes.

Knowing it will take a while, I can sit back and fall into a stately groove; it would be pointless to rush it anyway. Staring down a hundred papers to grade, I adjust my schedule, not my standards or the expectation that I might have a moment of free time after. Many of those emails didn't need answering anyway, a realization that, though I am late to it myself, many a sharper, faster worker never realizes at all.

Being a grind comes with its own sense of accomplishment, one I can't really share with others, since so much of our culture is obsessed with talent, efficiency, and speed. I can't brag that I worked 80 hours in a week since I only accomplished as much as someone working 45, but, damn it, I put the time in, didn't I?

The grind worries less about word count or chapters written and more about having engaged in the writing itself. There's a pleasure in the process, after all. I haven't gotten to the point at which writing or working or working out have become versions of a zen-like mindfulness. I have to grind out meditation, too. But I'm getting there.

I'm the opposite of this era's poster children, the ones who identify as ADHD, simultaneously set upon and lionized, claiming disability and the superpower to multitask, to livestream on YouTube while scrolling TikTok and updating Insta.

No, thanks. I'll spend the next hour writing two pages, maybe reading ten.

But maybe I'll also be able to spot the logical fallacies in some podcaster's diatribe, the wisdom of which you praise.

Just give me a minute. Maybe a day.

Misconceptions of the Left (and What to Do About Them)

 

Months out from the 2024 elections, the punditocracy is still nattering about why the Harris-Walz campaign lost. Most of this consternation relies on the following misconceptions, which have become holy writ on the left, and none of which are true.

There is such a thing as natural solidarity.

Not all Latin-Americans will naturally see their struggles as akin to those of Black Americans, or, especially, those of LGBTQI folks. Likewise for any other minority group, no matter their history of being oppressed. It's not just that the American public is decimated; it's that we're alienated from everyone else individually and between the groups with which we identify. For some, traditional ways of life or systems of belief pose further barriers: a Catholic of Mexican origin is likely to see herself as more aligned with other Catholics than with the queer Colombian kid down the street.

If the left wants to create a movement, build solidarity, raise consciousness, public education must commence.

Oppressed people cannot themselves hold discriminatory attitudes or practice discrimination.

This is a popular misconception on the right as well. Consider, though, that the same Puritans who, deposed from power in England, freely persecuted Quakers in the Massachusetts colony. Latinx folks can hate Black folks who can hate Asian folks. Remember the situation in Koreatown in the aftermath of the Rodney King beating? Seems like nobody on the left does anymore.

If the left wants to create a movement, reconciliation efforts need to happen and trust needs to be actively developed between potential coalition members.

Self-hatred/the acceptance of one's own oppression is impossible.

We woke ones may despise the Uncle Toms of the world or, at least, pity them, but recall that one of them has served on the Supreme Court for over 30 years. One way to get ahead in the world is to work hard; another is to buddy up to those who oppress you, telling them what they want to hear. One of the strongest advocates of bringing back feudalism in Chekhov’s The Cherry Orchard, Firs, was formerly enslaved by it.

Bucking the system can be heroic, and it may lead to progress, maybe even revolution. It also leads to trouble.

A hopeful sign that progress is possible is Cory Booker's historic 25 hour speech on the Senate floor, invoking John Lewis's idea of "good trouble." But we must build the groundwork for it by raising people's awareness of their own self worth and making the movement's goals and means safe, hopeful, and full of opportunity.

Established immigrants will naturally have fellow-feelings for recent immigrants.

The history of the US shows precisely the opposite. Even first-generation immigrants, once they have "made it" here, are notoriously disdainful of those "fresh off the boat." So familiar is this idea that there was even a mainstream sitcom with that title, yet we on the left somehow forget it as soon as the election cycle heats up. It took decades for colonial Englishmen to accept the Germans, for these newly minted "Americans to accept the Irish, for them to accept the Italians, and so on.

If we want to win, we need to revisit and celebrate the immigrant experience, yes, and to remind people of the hardships that brought people here to begin with and the hardships they faced building new lives. Why do you think the rightwing downplays, ignores, or, now, purges these stories from the public discourse?

We need to restore the public image of immigration as heroic, not as scurrilous.

The working class, farmers, and those lower on the income scale automatically understand their situation better than the "educated elites."

You'd have to be stupid or misinformed or both to believe that Donald Trump could magically lower grocery prices or instantly bring American manufacturing jobs back through tariffs or stop the war in Ukraine in 24 hours, yet millions of voting Americans believed exactly that. (Many still do, contrary to the clear evidence before them.) Working class people and farmers live in the same toxic media environment the rest of us live in, and they believe or reject misinformation based on a variety of factors, but because of generations of media programming, the one thing they believe about themselves is the "salt of the Earth" myth, that their judgments are more pure and more accurate because of, not despite, their lack of sophistication. The programming they receive, from AM talk radio, from Fox"News," from the pulpits of their churches and in their Facebook groups, though, is the sophisticated communication of educated people, people who don't have their best interests in mind. Their "commonsense" has been ginned up for them by the rightwing message machine.

It's dead wrong, but when it's all you know, and when it reinforces your own self-image, it starts to seem like the eternal truth.

And so, last of all, the left, if it wants to win, needs to play the long game, just as the right has done, thinking not one or two election cycles out, but decades, centuries, through, as we like to say about the environment, the seventh generation.

We love to hate on Project 2025, but, notably, we on the left don't have one, no playbook that articulates our aims, no "bible" to manifest our vision.

Given all this, it's no surprise that, despite most people agreeing with us on the issues, we continue to lose. But to win, we need to abandon these misconceptions and work hard to build the coalitions necessary for real progress to take place.

The Interminable Hell We're In

 We have to start getting used to the idea that Trump and Trumpism are here to stay.

Trump himself, while never of sound mind, and despite his atrocious diet, obvious obesity, and tanning addiction, seems relatively sound of body. Abetted by a compliant Supreme Court, a loyal and entrenched Republican party, and a toothless opposition, there's no reason to think we won't follow through on his signals to stay in office in 2028. Nursed along by the best health care available, it's possible he'll last another 20 years in office, increasingly demented but with lackeys whose power is dependent on his continued figurehead of the MAGA cult.

Having recreated the federal bureaucracy not only to enable authoritarianism but to guide that authoritarian system to support a handful of tech-minded oligarchs, there's no reason to think that Musk, Bezos, Zuckerberg, won't continue to support the regime that continues to support them. And even if one of them decides to depose Trump and install himself as dictator for life (and none of these men is all that old), there's little anyone would be able to do about it, with the federal system designed to avert such a thing as eroded as it already is.

Once power is completely aligned under Trump, which is almost already the case officially the case and clearly the case de facto, even a legal ouster under the 25th Amendment or an extra-legal ouster by other means won't, by themselves, restore democracy. The coup leader, be it JD Vance or someone else—Trump Jr., for example—would simply be installing himself atop an existing authoritarian system, not reforming one. And that would be the point: those in power now haven't gotten there because they have principles or value the popular will.

The idea that all authoritarian systems fall on their own, that they must give way, eventually, to the needs of the people, is specious: witness Spanish fascism, which lasted under Franco for almost forty years. Note that Castro's Cuba chugs along long after the revolutionary's demise. And then there's North Korea, now on its third generation of dynastic rule. Despite its recent transformations, "communist" China is still a repressive, one-party state, nearly eighty years after Mao's rise to power.

None of this is meant as an excuse for pessimism; it's simply meant as a warning: there is no natural end to dictatorship. For every Hitler, Mussolini, Ceaușescu, there are half a dozen others who never paid from their crimes, who, like Stalin, Franco, Castro, died in peaceful slumber, with nary a worry in mind.

Getting rid of dictators is not a political process. Instead, it is a matter of justice, and the failure of the Congress to find Trump guilty when it had two chances through impeachment, the failure of the State of New York and the federal justice system to jail Trump (or offer him exile), the failure that was the Supreme Court's ruling in Trump v. USA have all but sealed our fate. With Democratic leadership capitulating to Trump and Republicans repulsively loyal, it's difficult to see any way out, hard to see just who, what leader or popular uprising, will be willing to wield the hammer of justice to nail the coffin shut on Trump, his movement, and all it entails.

But without it, we better get used to living in this hell for the long haul.