A pitchfork is perfect for moving hay, compost, and the messy ensemble of cow poo that accumulates in barns. And the five sharp tines get attention by someone angry when the banker and landlord are insufferably arrogant. The wealthy are usually surprised. I know I was surprised last month as my party and candidates were so rudely put aside in favor of….well, you know.
Once anger flames, rationality has nothing to do with what happens next. Righteous anger can open the way for cynics with very ugly intentions to do things nobody voted for. Who voted for polio, measles, coat-hanger abortions and run-amok preachers? This is why Project 2025 was buried during the election and whipped out immediately after. This is why North Carolina losers used anger’s shadow to change the job descriptions of those that won. Ugly. And predictable.
Even when it is obvious that anger is being used by opportunistic frauds; it does not mean the anger will subside. Or that it will suddently become smart and be redirected toward the billionaire blowhards that actually do deserve a pitchfork.
What to do? Don’t argue with angry people, especially by telling them they are foolish to trust such obvious frauds. They don’t want instruction, especially from people like me they see as part of the “elite” that reminds them of their stolen dignity every time they go to the grocery store, bank, school or hospital.
Let’s talk about the hospital part of the conflagration. That’s the one I know best, having been inside the beast for nearly twenty years until recently. Why would anyone be angry at a hospital since everyone is going to need one? Normal people (the angry ones) understand that the shiny medical castles are only partly there for them. Hospitals are one visible knot in a complicated web of privileged guilds and professions including, executives, bankers, doctors, nurses, suppliers, technology companies, insurance companies, pharma, ambulance drivers, all seamlessly integrated into the government and universities. All that feels quite personal one is vulnerable and in pain with no possibility of negotiating anything.
All parts of the system—cruelly called “health”—seem to be more and more obviously about money—theirs—and less and less about those who need their “care” (the services people cannot not buy). This system costs roughly a trillion dollars a year and yet wants more. It drives every in the economy cost higher while whining all the time that it isn’t enough. Ironically, many of these hospitals (including my own) are not supposed to be “for profit,” so they do not pay taxes. All of this is painful at the family level only beginning with insurance and the huge indecipherable bills that result when you actually need the services. It makes the economy sick as every business thinks constantly about how to offload these costs onto vulnerable gig-workers or by shifting everything possible across the border or replacing humans with robots.
This interwoven system is the leading cause of bankruptcy in most states (for medical debt under $5,000). So who needs democracy when I can’t take my kid to the doctor without risking eviction or having my car towed away?
Pitchfork.
It is ironic that this web of privilege thinks it (we) are protected by our non-profit status and science. Who could quarrel with charitable scientists? Well, we don’t look charitable and we don’t look scientific. Offensive executive and physician pay levels pulls one fig leaf away. The other fig leaf—science—disappears as it is always used to justify another shinier and more expensive building. What about the low-cost and low-tech science of prevention that makes at least some of those buildings unnecessary? Silence. What about the science supporting investment in education, faith and good stable jobs? Maybe later. What about the science linking democracy and neighborhood stability to health? Sounds woke. Everybody in healthcare knows that science, but we build bigger buildings instead of following it. So the angry people give us a Secretary of Health who doesn’t believe in science either.
The whirlwind is partly our fault. Those of us who do believe in that science and do believe in the non-profit mission should have been far more aggressive in pushing the medical industrial complex to act appropriately. Instead, we prodded gently and waited for a better time.
It’s not too late. Dr. King said it is always the right time to do right. It is crucial that we not be pulled into defending the indefensible. Not everything is worth defending from president Musk who will be losing support pretty quickly on his own. And as you pull apart the data we should notice that some of those most angry are people friends. This might be a good time to lend some intelligence by helping aim the energy where it can do some good, instead of bad.
For instance. I offer two minor tweaks to non-profit health policy everyone should agree with:
First, hospitals’ non-profit tax status now rests on superficial “community benefit” rules. It should never have been allowed to be superficial. Those rules have little to do with the science of prevention and social determinants because implementation plans have no accountability to local public health (except in Ohio which is a story for another blog).
- Give the local public health department authority to approve the hospital’s community benefit implementation plan so that it aligns with actual public health science and local government. This has been discussed quietly at the National Academies of Science for years. But religious hospital lobbyists fought it (!?!?!?!) It would have been better to make the hospitals uncomfortable, Than having the voters angry. Do it now.
Second, hospitals are huge financial enterprises which often make as much money from their investments as from selling expensive medical procedures. It is likely they have about a trillion in their basement, which nobody ever thought possible. But there it is; they are banks that also offer medical services. Legally, their investments are invisible to their non-profit status; they aren’t required to report how much investments they have. They are usually required by their bankers to have between 100-300 “days of cash on hand”. Take your local hospital’s annual revenue and do the arithmetic. Unlike hospitals, your local banks are required by the Federal Reserve to invest some of their corpus in places impacted by their historical racism. Why not hospitals, which have done the same in the past (usually to the identical neighborhoods)?
- Add transparency to the legal “community benefit” form. And give the Federal Reserve responsibility to oversee non-profit investments instead of the IRS.
Dumb is going to happen. But the chaos breaks open some room to do some good things, too. This is a great time to speak very specifically about how our public goods can be available to everyone no matter how they voted, prayed, worked, worried or shouted. If we use the pitchfork to shovel out the barn, nobody needs it as a weapon.
