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I BelieveGovernance and Philosophy in America A Top 10 Apple Philosophy Podcast Author: Joel K. Douglas
Governance and Philosophy in America A Top 10 Apple Philosophy Podcast joelkdouglas.substack.com Language: en Genres: Government, Philosophy, Society & Culture Contact email: Get it Feed URL: Get it iTunes ID: Get it |
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We Are All Republicans, We Are All Federalists
Tuesday, 19 May, 2026
Dr. Nick van Terheyden had bone pain that he could not explain. He was fifty-eight, a physician in Maryland. A specialist ordered a $350 blood test for vitamin D deficiency. The test came back positive. The deficiency was severe enough that if left untreated, it would lead to osteoporosis.Van Terheyden’s insurer was Cigna. They refused to pay for the test.The corporate medical director who signed the denial letter said the test wasn’t medically necessary. Van Terheyden read the letter, looking for the clinical reasoning. There was none. Only generic language, a response from a machine. He filed an appeal. A second medical director upheld the denial. To reimburse van Terheyden for the test that had come back positive, van Terheyden would have to prove he had a vitamin D deficiency before the test had been done.He kept investigating. Cigna used a system that flagged mismatches between billing codes and acceptable diagnoses. It let the company’s medical directors deny claims in batches without opening a patient’s file. Internal documents later showed that the doctor who rejected van Terheyden’s claim rejected roughly sixty thousand claims in a single month. Over a two-month window, Cigna physicians denied more than three hundred thousand payment requests. The average review took 1.2 seconds.It took seven months and an external medical review to force the insurer to pay the $350.Two years passed. On December 4, 2024, a man named Brian Thompson stepped out of a New York hotel and was shot dead on the sidewalk. He was the chief executive of UnitedHealthcare. Shell casings left behind were inscribed with three words: deny, defend, depose. Across demographic lines, Americans began telling their own stories. Denials, delays, bankruptcies, deaths. The shooter had read the same files Dr. van Terheyden had. So, it turned out, had millions of others.The event left a question America still cannot bring itself to ask out loud.What would it take to build a healthcare arrangement Americans can actually live with?Act I. The BodyIn Centerville, Ohio, Tim Anderson watched his wife die for three years.Doctors diagnosed Mary Anderson with amyotrophic lateral sclerosis. ALS destroys motor neurons one at a time. The body loses the ability to walk, then to swallow, then to speak, then to breathe. The mind stays. The patient is awake for all of it.By the end, Mary could no longer move her arms or her legs. She could no longer eat without help. Her voice was going. Her physicians prescribed equipment to help her breathe and to help her speak.The Andersons were insured through UnitedHealthcare. UnitedHealthcare denied both claims.Tim Anderson appealed. The company denied the appeals. He appealed again. The denials continued. The medical necessity of the equipment was not in dispute among Mary’s doctors. The diagnosis was not in dispute. The progression of the disease was not in dispute. The only substance in dispute was whether the insurer would pay.The Andersons could not get coverage for the machines that would have helped Mary breathe or speak. Toward the end, Mary communicated by blinking when Tim held up pictures. The family relied on donations from a local ALS group to cover what their insurance had refused.She died in 2022.After the shooting on the sidewalk in New York, Tim Anderson spoke to a reporter. He said this: “The business model for insurance is don’t pay. When Mary could still talk, she said to me to keep fighting this. It needs to be exposed.”The Andersons live in red, rural Ohio. Tim Anderson is sixty-seven. He worked his whole adult life, paid his premiums, raised his family. He didn’t enter the healthcare debate through ideology. His wife’s battle brought him into it anyway. Eight hundred miles south, in Jefferson, Georgia, Luke Seaborn opened a shop to restore classic cars.Seaborn was fifty-four. He had been trained as a chemical engineer and had spent years in corporate work before leaving to do what he loved. The shop was small. The private insurance market for a small business owner in rural Georgia was punishing. For himself and his son, the premiums were close to impossible.In 2023, Georgia’s Republican governor Brian Kemp launched a program called Pathways to Coverage. It was a Medicaid waiver with a work requirement. Eligible Georgians could enroll if they could prove they were working, studying, or volunteering at least eighty hours a month. The program was designed as a conservative answer to Medicaid expansion. It tied coverage to personal responsibility.Seaborn enrolled. He believed in what the program said it was. He was grateful for the coverage. When the governor’s office asked him to film a promotional video, he agreed. He stood in his shop, surrounded by vintage Fords, and praised Pathways as a blessing. The governor used the footage to argue that work requirements foster independence.Then the program began to fail him.Seaborn logged his eighty hours every month, as required. In November, the state canceled his coverage. The state had quietly introduced a new form. It required enrollees to periodically re-enroll by re-entering the same information in a different format. Only an insurance executive Seaborn had met during the promotional shoot could restore his benefits. He had to call her directly.A few months later, a software glitch stopped his text alerts. He logged into the portal in March and discovered his coverage was set to terminate on April first. The state said he had missed an annual income statement. His policy was not yet due for renewal. He could not reach a caseworker by phone. He paid out of pocket for his family’s medications while he tried to fix it.The Pathways program had cost Georgia taxpayers more than eighty-six million dollars by then. More than fifty million had gone to Deloitte Consulting to build the portal. The program had enrolled barely three percent of those eligible.Seaborn said this to a reporter: “I am so frustrated with this whole journey. I did what I was supposed to. But that wasn’t good enough.”Two Americans. Different states. Different tribes. Different illnesses and programs. UnitedHealthcare denied Mary Anderson’s breathing machine. The State of Georgia’s Medicaid portal canceled Luke Seaborn’s coverage. One was private corporate denial. One was public administrative failure.They are the same failure.In both cases, a working American did what the system asked. Paid the premiums. Filed the forms. Logged the hours. Played by the rules of the arrangement. In both cases, the arrangement failed to honor its own terms. The diagnosis, the mechanism, the grief. These are not partisan. The conservative rancher’s widow and the conservative small-business owner are not the only Americans this happens to. The diagnosis runs the country.Healthcare administration, then, is not a debate. It is a machine.Act II. The ArchitectureIn Holly Springs, Mississippi, Dr. Kenneth Williams runs the only hospital within twenty-five miles.Williams is a family physician and the chief executive of Alliance HealthCare System. Holly Springs is in Marshall County. Marshall County has about thirty-eight thousand people. The next-closest hospital is a long drive. Williams has been there since 1999. Sixty to sixty-five percent of his patients are on Medicare. When Medicare Advantage came into the program in 2006, the math of running his hospital changed.For five years before that, Alliance had been profitable. After Medicare Advantage took hold, the hospital lost almost two million dollars in a single year. Denials came in patterns Williams had not seen before. Insurers rejected treatments his physicians ordered. Insurers a thousand miles away shortened stays his physicians said were necessary. The denials killed a geriatric psychiatry program Alliance had built to serve the county’s elderly. The hospital had to close it.Williams was blunt about the system and the insurers. “I knew that our hospital couldn’t exist under the payment system it is under right now,” he said. About the insurers he went further: “They don’t want to reimburse for anything. Deny, deny, deny. They are taking over Medicare and they are taking advantage of elderly patients.”The hospital had already ended inpatient care in March 2023. Then they had to close the only emergency room in Marshall County in April 2024. Williams kept what he could: outpatient services, the clinic, the lab. The architecture had dismantled the rest of his hospital, floor by floor. When a reporter asked him who suffered from the closures, he answered in two words. “My patients.”Williams does not know Dr. Nick van Terheyden. He has never read the ProPublica investigation of Cigna’s algorithm. He has not seen the internal documents showing what 1.2 seconds per claim looks like on a corporate scorecard. He does not need to. He has watched the same gears grind his county for more than twenty years. He watched it kill a psychiatry program for elderly people in rural Mississippi. He watched it nearly kill the hospital itself.The Maryland physician saw the algorithm. The Mississippi physician saw the cemetery.This is the architecture America built. Whether by design or by negligence, we built it.A patient gets sick. A doctor orders a test or a treatment or a piece of equipment. A system designed to find reasons not to pay reviews the order. A doctor does not. The reviewing doctor, if there is one, does not open the file. The system issues the denial. A second reviewer hears the appeal and upholds the first. The patient appeals again, if the patient has the time and the literacy and the energy. Most do not.The question this architecture raises is older than the architecture itself. Who decides? Who has the authority to decide what shall be done with a human body? The person whose body it is, the doctor she has chosen to examine her, or a corporate medical director who has never met her and will not open her file?The American tradition has an answer. The patient and her physician. The body is the first property a person owns, and the right to decide what happens to it is the foundation of the right of liberty. No one has the authority to override that judgment. Not the state. Not a corporation. Not an actuary. The arrangement America built does this routinely. It is our business model.The question of who decides is only half of the moral architecture. The other half is older than the Republic.The race is not to the swift, nor the battle to the strong, nor bread to the wise. Time and chance happen to us all.Mary Anderson did not choose ALS. The patients in Marshall County did not choose to be born into a county that lost the only mental health service it had. Time and chance fell on them, inside a system we built as if we believed time and chance did not exist.A healthcare arrangement worthy of the American tradition has to do two things at once. It has to preserve the liberty of the patient and the physician. And it has to provide a floor against the cruel net. The arrangement America built fails at both. It overrides patient and physician judgment through automatic denial, and it leaves people bankrupt when the net falls anyway. It violates liberty without providing security. It manages neither responsibility nor mercy.The country has lived with this long enough to recognize what it is doing. Tim Anderson knew when UnitedHealthcare denied his wife’s breathing machine. Luke Seaborn knew when Georgia’s portal canceled his coverage. Williams has known since 2006. Van Terheyden since 2021. This isn’t partisan.The architecture is the disease. The tougher question is, what do we do about it?Act III. The Long WallsIn Big Sandy, Montana, Shane Chauvet was working his ranch when a windstorm came up.Big Sandy sits on the high prairie just north of the Missouri Breaks. Eight hundred people. One hospital. Twenty-five beds. The Big Sandy Medical Center is what the federal government calls a critical access facility. For the ranchers and farmers of that part of Chouteau County, it is what stands between a bad day and a fatal one.The wind that afternoon was strong enough to tear pieces of metal off the outbuildings. A sheet of it caught Chauvet as it flew. The cut nearly took his arm off. His wife loaded him into a truck. They drove to the hospital. They found the emergency room doors locked. The wind had knocked out the power across the county and the staff had moved to a side entrance to run the building on generators. Chauvet’s wife pounded on the doors while his blood pooled on the ground. Someone heard her.The medical staff at Big Sandy stabilized the arm. Then they put Chauvet in a ground ambulance and drove him eighty miles through rain and hail. Chauvet credits the hospital with saving his arm and his life. He told a reporter what he had learned. “I always would say, ‘Oh, they’re nice to have,’ but now I look at the hospital and say, ‘That’s essential to our community.’”The Big Sandy Medical Center may not be there in five years.Since 2010, nearly one hundred rural hospitals across the United States have closed. The reasons are not mysterious. Medicare Advantage and commercial insurers pay below the cost of providing care. The denials grind the margins to nothing. The closures begin with inpatient services, then the emergency room, then the doors. Marshall County, Mississippi, lived through this with Dr. Williams’ hospital between 2023 and 2024. Chouteau County, Montana, is one storm away from watching it happen to its own.When the cruel net falls on a working American in rural America, the architecture that catches him is fragile. The system that overrides his physician’s judgment when he is sick is the same system that dismantles the hospital that will keep him alive when the wind picks up.The architecture that is the disease is not in question. The country has known what its healthcare arrangement is doing for years. The tougher question is, what do we do about it?A national single-payer healthcare system makes sense. Lower administrative cost, universal coverage, the bargaining leverage to discipline pharma and provider pricing, and the elimination of bureaucratic violence.There’s nothing radical about people having healthcare, jobs, and education. We find money for what we prioritize. An America that wanted to make this transition could do it.And it will fail catastrophically if one party passes it 51-49, because half the country will spend the next forty years trying to dismantle it, and the instability of that fight will produce worse outcomes than the broken system it replaced.In May 2026, a prominent progressive leader vying for a presidential run described single-payer healthcare in a single word: forever. Presidents, senators, and elected officials come and go. Single-payer healthcare would outlast them all.This is the language of division. One tribe passes structural reform over the other and locks it in beyond the reach of reversal. And it is exactly the move that guarantees the reform’s failure.The Affordable Care Act is the proof. It passed in 2010 on a party-line vote; every Republican administration since has worked to dismantle it. Every Democratic administration has worked to expand it. Sixteen years later, hospitals cannot plan. Insurers cannot plan. Patients cannot plan. The rules change with every election. The instability is its failure.Now imagine that fight scaled to the entire healthcare economy. Every two years, every four years, the question reopened. A country that cannot agree on how to administer an insurance subsidy cannot administer a national healthcare system passed by half of itself over the other half.The alternative is consensus. Medicare is the proof. It passed in 1965 with substantial Republican support; seventy House Republicans, thirteen Senate Republicans. It has survived sixty years because both parties helped build it. Both parties campaign on protecting it. The durability of consent.Ancient Athens and its port lay four miles apart. The countryside between them belonged to no one in particular and to every army that crossed it. After the Persian Wars, during the half-century the Athenians later called the Pentecontaetia, the city built two parallel walls along the road to the sea. The walls connected the city to the port. They made the four miles between the city and the port indistinguishable from the city itself. An enemy could blockade the city, and grain could come in. Ships could be supplied. The city could not be starved out so long as the walls stood.The walls cost a generation of argument to build. Sparta opposed them. Athenian factions opposed them. The Athenians built them anyway because the men who remembered the Persian invasion understood that a city cut off from its port was already lost. They built across disagreement. They built because the alternative was a slow surrender to anyone who could control the road.The framers understood this. The Constitution that we have was the product of a long summer of argument, compromise, and the deliberate construction of an architecture meant to require ongoing consent rather than one-time victory. We argue about Senate representation and the Electoral College, but the small states would not have joined the Union otherwise. The whole document is an exercise in building across difference.Healthcare in America has to be built the same way, or it cannot be built at all.The arrangement we build cannot belong to one tribe. The progressive who calls single-payer forever and the conservative who calls all collective provision socialism are both refusing the harder work, which is the work of building something that survives them. The Republic does not run on wishes and mandates. It runs on consent.In March 1801, after one of the bitterest elections in American history, Thomas Jefferson stood on the Capitol steps and addressed a country that had nearly broken under the strain of the contest he had just won. We are all Republicans, he said. We are all Federalists. He was telling the country that the legitimacy of the new arrangement required incorporating the people who had lost the election, not ruling over them.Healthcare reform of any kind demands the same consensus from a generation that has mostly forgotten how to gain it.The architecture is the disease. We built it. We can build something else. We will not do it as Republicans. We will not do it as Democrats. We will do it as Americans, or we will not do it at all.SourcesPatrick Rucker, Maya Miller, and David Armstrong, How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them. ProPublica and The Capitol Forum, March 25, 2023. The investigation that exposed the PXDX system, Dr. Cheryl Dopke’s sixty thousand denials in a single month, and Dr. Nick van Terheyden’s seven-month appeal for a three-hundred-fifty-dollar test.PBS NewsHour, UnitedHealthcare CEO Shooting Opens Floodgates of Americans’ Insurance Frustrations. December 2024. Primary source for the Tim and Mary Anderson story, including the denial of equipment to help Mary breathe and speak, and the pictures Tim held up so Mary could blink.Margaret Coker, He Became the Face of Georgia’s Medicaid Work Requirement. Now He’s Fed Up With It. ProPublica and The Current GA, May 14, 2025. The Luke Seaborn story, the Pathways portal failures, the Deloitte contract, and the three-percent enrollment figure.Gretchen Morgenson, ‘Deny, Deny, Deny’: By Rejecting Claims, Medicare Advantage Plans Threaten Rural Hospitals and Patients, Say CEOs. NBC News, October 31, 2023. Source for Dr. Kenneth Williams’s quote about Medicare Advantage practices.Anna Wolfe, Holly Springs Hospital Ends Inpatient Care. Mississippi Today, March 31, 2023. The 2006 financial losses at Alliance HealthCare System and Williams’s diagnosis that the hospital could not survive under the existing payment system.Anna Wolfe, Marshall County’s Only ER to Close. Mississippi Today, April 11, 2024. The April 2024 emergency room closure and Williams’s two-word answer to the question of who suffered.Dr. Kenneth Williams, The Future of Healthcare in Marshall County. The South Reporter, March 26, 2026. Williams’s own guest column to his community. The landlord-and-tenant framing and the January 2025 presentation to the Marshall County Board of Supervisors.John Locke, Second Treatise of Government. 1689. Chapter V, particularly section 27: “Every man has a property in his own person.” The foundation of the property argument in Act II.John Stuart Mill, On Liberty. 1859. The harm principle and the structural question of who has authority over the individual.Ecclesiastes 9:11–12, King James Version. The race, the battle, the bread, and the cruel net.Aaron Bolton and Arielle Zionts, Give and Take: Federal Rural Health Funding Could Trigger Service Cuts. KFF Health News and Montana Public Radio, March 27, 2026. The Shane Chauvet story, the Big Sandy Medical Center, and the Rural Health Transformation Program's risk to rural hospitals.University of North Carolina Cecil G. Sheps Center for Health Services Research, Rural Hospital Closures. The standard primary source for tracking rural hospital closures since 2005.Pocharapon Neammanee, AOC Responds To Assumptions Of 2028 Presidential Run. HuffPost, May 9, 2026. Representative Ocasio-Cortez at the University of Chicago Institute of Politics in conversation with David Axelrod: “Presidents come and go, Senate, House seats, elected officials, come and go, but single-payer healthcare is forever.”Social Security Administration, The Corning Years: Medicare Is Enacted. The official history of the 1965 Social Security Amendments, including the bipartisan roll-call votes that created Medicare. Seventy House Republicans and thirteen Senate Republicans voted yes.Thucydides, History of the Peloponnesian War. Book I, sections 89–93, and Book II, section 13. The Pentecontaetia and the construction of the Long Walls between Athens and Piraeus.Thomas Jefferson, First Inaugural Address. March 4, 1801. “We are all Republicans, we are all Federalists.” The constitutional move that named this essay.Companion PiecesAmericans’ Unalienable Right to Life. Healthcare as a component of the unalienable right to life. The Declaration, the Wyoming Constitution, and the right of the competent adult to decide.Should the American People Fund Cancer Research at Harvard?. The same architectural critique extended to pharmaceutical pricing. Taxpayers fund the research, universities patent the discoveries, drug companies set the prices, and the constitutional test for public spending goes unanswered.The Price Is the Price: A Letter to Raging Moderates. The minimum wage essay. Lincoln, the Long Walls, and consensus as the precondition for structural reform. Get full access to I Believe at joelkdouglas.substack.com/subscribe
