Stop Calling It Broken

A System Working Exactly as Designed

The woman in front of me at Walgreens last Tuesday could not afford her insulin.

I know this because I heard her ask the pharmacist how much it would cost at the other pharmacy across town. The pharmacist checked. Three hundred and forty dollars. The woman left without the insulin.

I got my blood pressure medication. Eight dollars with my insurance.

The woman drove away and I stood there in the February cold thinking about systems that work and systems that don’t and the language we use to describe the difference.

We keep calling it broken.

It’s not broken.

I’m sixty-six years old. I live in western Nebraska with my wife Patricia, who is fifty-five and has been a nurse her entire adult life. Last year she had a major heart attack. They helicoptered her to Colorado. Ten days in the hospital. The bill was $437,000.

We are comfortable. My father did well in business.At one time I did OK in business too.Left us enough that we never had to choose between rent and food. Patricia works with a net underneath her,a husband with family money, retirement,options most nurses don’t have.

This is what comfortable means. This is what complicit means.

I write this because watching what happened to Patricia made me understand something I’d been pretending not to see for decades: the system isn’t failing. It’s succeeding. Just not for us.

Let me tell you what happened.

Last year,Super Bowl Sunday.

I told this story once but let me tell it one more time.

Kansas City playing. Not because I cared much about football, but because Taylor Swift did, and that was enough for Patricia and the girls.

The house was full. Four kids, five grandkids, tortilla-warmed plates balanced on knees, everyone yelling over each other and the TV and the smell of carnitas still lingering in the kitchen.

The youngest one, Jackson, had painted his cheeks green and white, wearing his 4T Eagles jersey. Someone had wrapped an old jersey around Stella the dog. Someone had spilled Modelo on the couch but no one moved to clean it.

These are the kinds of nights that blur into one another. The noise, the joy, the familiar weight of family.

Patricia stood by the kitchen sink, rubbing the base of her neck.

She’d been tired for weeks. That long, dragging tired that clings to you no matter how many hours you sleep. But what mother isn’t tired? What nurse isn’t used up by the end of a week? What woman in her fifties isn’t a little worn out by life?

She’d ignored the headaches, the shortness of breath when she bent down to pick up a dropped spoon. Chalked it up to age, to stress, to forgetting to drink enough water.

The pain didn’t come all at once. It started in her upper back, a low heat beneath her shoulder blades. The kind of ache you get when you sleep wrong or spend too long on your feet. Then came the pressure. Not pain, not yet. Just a tightness, like something pressing against her chest from the inside.

She set down the plate.

She gripped the edge of the counter.

She stayed very still.

She was not in pain. Not in the way we’re taught to expect pain. Her chest didn’t seize. She didn’t clutch at her heart like women in movies. She didn’t fall. She didn’t gasp.

Instead, she breathed. Carefully. Shallowly.

There was a heat in her neck now. Her jaw ached. Her arms felt wrong. She doesn’t know how else to say it. They felt wrong. Like they belonged to someone else.

Still, she didn’t speak.

Because she could breathe. Because she could move. Because she had enchiladas to reheat.

I was watching the game. Half-attentive. Not on my laptop for once. Just sitting there.

Then I looked at her and I knew.

I saw it in her face. The confusion, the fear, the wrongness.

I called 911.

My hands were shaking. My voice was shaking. The paramedics came. They used her name. They asked about aspirin. Patricia answered like a nurse. Clinical. Calm.

The grandkids were herded into the back bedroom. The game was turned off. Kansas City was already losing.

The hospital in our town no longer has a cardiac department.

They airlifted her to Loveland, Colorado.

I drove four hours in the dark. Highway lights flashing. Radio off. Replaying her face. That stillness. The way she looked at me across the room and didn’t say a word.

At the hospital, the lights were so bright they felt like noise.

Doctors moved quickly.

Words like “widowmaker.”

Words like “blockage.”

Words like “now.”

Three arteries. Two nearly closed. One fully blocked.

Three stents.

They cut into her wrist and navigated into her heart. Her heart that had kept ticking through births, funerals, night shifts, quinceañeras, and long mornings when she could not find the strength to get out of bed.

Her heart finally said no.

Ten days in that hospital. Ten days of tubes, wires, blood thinners. Ten days of nurses adjusting pillows and asking about pain on a scale from 1 to 10.

The doctors were incredible. The nurses were incredible. The helicopter crew, the ICU staff, the surgeons. Everyone did their job and did it well.

The system worked.

And then the bill came.

$437,000.

Let me be specific about what $437,000 buys you:

A ninety-minute helicopter flight: $54,000.

Ten days in the hospital: $383,000.

Three stents that will keep my wife alive: included in the above.

We have good insurance. We’re comfortable. We can afford this.

But here’s what I kept thinking: What if we couldn’t?

What if we were the woman at Walgreens who can’t afford insulin that costs six dollars to manufacture and three hundred forty dollars to buy?

Patricia would be dead.

Not because the doctors didn’t know how to save her. Not because the medications don’t exist. Because we couldn’t afford them.

And that’s when I understood: the system isn’t broken. The system works perfectly.

It works for pharmaceutical companies posting record profits while people ration insulin.

It works for insurance companies denying one-third of claims while their CEOs make $142 million.

It works for hospital corporations and helicopter companies extracting maximum value from crisis.

The system is designed to extract maximum profit from illness. And it succeeds brilliantly.

Patricia came home after ten days. Weak. Scared. I’d never seen her scared before.

The first thing she did,the first day home,was get on the phone with the insurance company.

Trying to understand the bill. Trying to figure out what we owed. Trying to calculate copays for her medications.

I watched her do math. Watched her face as she calculated. Watched her start to cry,not from pain, from rage.

“This is what it’s like,” she said when she hung up. “Being my patients. Trying to figure out if you can afford to live.”

“Patricia, we can afford…”

“I know we can afford it, Tom. That’s not the point.” She was shaking. “The point is I’ve spent my entire career in a system that does this to people. And I told myself I was helping. And then the system did it to me.”

Here is what took me decades to understand: the language is not neutral.

When we call the system “broken,” we imply malfunction. We imply the system is trying to help and failing. We imply that fixing it means adjusting mechanisms, replacing parts.

But what if it’s running fine? What if it’s doing exactly what it was designed to do?

Then fixing it means confronting the design. Who it serves. Who pays. Who benefits. Who bleeds.

Patricia tried to explain this to me for years. She’d come home from shifts and tell me about people dying because they couldn’t afford care. And I’d say “the system is so broken” and she’d look at me like I was missing the point.

I was missing the point.

The point is: it’s not broken. It’s working.

Let me show you how this works in practice.

Twenty-three thousand people die every year in America because they don’t have health insurance. Not because healthcare doesn’t exist. Because they can’t afford it.

We spend twelve thousand dollars per person per year on healthcare. Canada spends fifty-five hundred. The UK spends forty-five hundred. We pay double for worse outcomes. Lower life expectancy. Higher infant mortality. More preventable deaths.

This is not market failure. This is the market working.

The market maximizes profit. Healthcare maximizes profit by extracting value from illness.

Patricia sees this extraction every shift:

The sixty-two-year-old man who delayed coming in with chest pain for three days because he was between jobs and had no insurance. By the time he came in, too much damage. He died in the ICU. His wife got a bill for eighty thousand dollars for the privilege of watching him die.

The woman who chose between her blood pressure medication and her rent. Chose rent. Had a stroke. Now she’s in a nursing home at forty-seven. Medicaid pays for the nursing home. Wouldn’t pay for the fifteen-dollar medication that would have prevented the stroke.

The diabetic who’s been rationing insulin for three months. Comes in in DKA. They save her. She gets a bill for thirty thousand dollars. She makes fourteen dollars an hour at a call center. No benefits. She asks Patricia if she could just die next time because she can’t afford this.

Patricia tells her about financial assistance programs. Helps her fill out paperwork. Knows the programs are designed to look like help while ensuring most people don’t qualify. And even if this woman gets assistance this time, she’ll be back. Because she still can’t afford insulin. Because the system needs her desperate.

Medical debt is the leading cause of bankruptcy in America. Not medical failure. Medical debt.

People ration medication. People delay care until conditions become catastrophic. People die preventable deaths.

Not because we don’t have enough doctors. Not because we don’t have the technology. Not because the medications don’t work.

Because healthcare is organized to extract maximum profit from illness.

While insurance executives make hundreds of millions. While pharmaceutical CEOs buy third homes. While hospital administrators get bonuses for cutting nursing staff.

The CEO of UnitedHealth made $142 million in 2021. His company denied 32% of claims that year.

He made $142 million ensuring that one-third of people who thought they had insurance didn’t actually have insurance when they needed it.

The system produced exactly the outcome it was designed to produce: maximum profit extraction from human suffering.

The cruelty is not a bug. The cruelty is the business model.

Patricia has been a nurse her entire adult life. She knows something I didn’t want to see:

The system needs people desperate. Desperate enough to work for poverty wages. Precarious enough to accept exploitation. Scared enough to stay compliant.

If everyone had their basic needs met,housing, healthcare, food, education,you couldn’t exploit them. They could refuse bad jobs. Demand better wages. Organize. Strike.

So the system prevents that. Deliberately.

This is why universal healthcare won’t pass despite overwhelming public support. Why Medicare for All gets called “unrealistic” despite being cheaper than what we have. Why every other developed country can do it but we can’t.

Our desperation is valuable. Our precarity is profitable. Our fear is functional.

“You think it’s conspiracy,” Patricia said once. “It’s not conspiracy. It’s just capitalism doing what capitalism does. Maximizing profit. Our desperation is profitable. So the system produces desperation.”

Let me tell you what radicalized me.

Not theory. Not books. Experience.

Watching Patricia nearly die.

Driving four hours in the dark not knowing if she’d be alive when I got there.

Watching the bills come.

Watching her,barely recovered,navigate a system designed to confuse and extract.

Watching her cry from the realization that the system she’s served for forty years tried to kill her with stress and then charged us $437,000 to save her.

But more than that: understanding that I’d been one of the comfortable people explaining why universal healthcare is “unrealistic.” Why we have to work within the system. Why we can’t let perfect be the enemy of good.

“Don’t let perfect be the enemy of good” sounds reasonable until you understand what it actually means: “Accept that some people will suffer so I can stay comfortable.”

That’s what it has always meant.

Patricia came into the kitchen last night while I was writing this. Late. February in Nebraska,wind that never stops, cold that settles in your bones.

She had her wine. I had my whiskey.

“You’re angrier now,” she said.

“Yes.”

“You sound like you just discovered the world is unfair.”

“I’m sixty-six years old. I should have discovered it sooner.”

“You did discover it. You just didn’t want to see it.”

She was right.

“What changed?” she asked.

“You almost died. And they charged us $437,000 to save you.”

“We can afford it.”

“That’s not the point.”

“I know it’s not the point.” She touched my shoulder. “But don’t write this like you’re the only one who just figured out the system is designed to extract. I’ve been watching this for decades. People die every shift because they can’t afford care. Write it. But write it angry at the right things.”

A few nights later, Patricia came home late from a bad shift.

“Tell me,” I said.

She sat down. Poured her wine. Took a drink.

“Fifty-three-year-old woman. Nurse, actually. Works at a clinic across town. Came in with chest pain. Classic presentation. We got her stable, did the workup. She needs cardiac catheterization. Probably stents.”

“Okay.”

“She asked how much it would cost. I told her I didn’t know the exact amount but with her insurance it should be manageable. She asked what manageable meant. I said probably a few thousand in copays.”

Patricia took another drink.

“She said she just refinanced her house. Her oldest is starting community college. Her deductible resets in March. She asked if we could wait.”

“Wait?”

“She wanted to go home. Think about it. See if the pain came back.”

“She left.”

“What?”

“She left AMA. Against medical advice. Said she couldn’t afford a few thousand dollars. She’s a nurse, Tom. She works full time. She has insurance. And she can’t afford to get her heart fixed.”

“Jesus.”

“Her name is Maria. She’s my age. She has three kids. And she left the hospital with maybe a blocked artery because she can’t afford the copay to fix it.”

We sat there in silence.

“Did you tell her what would happen if she doesn’t get it fixed?”

“Of course I told her. She knows. She’s a nurse. She knows exactly what will happen. And she still chose the copay over her life because if she dies, at least her kids don’t inherit her medical debt.”

This is what I mean when I say the system is working.

Maria is a nurse. She has a job. She has insurance. She did everything right.

And she’s going to die because she can’t afford the copay to save her life.

The system produced this outcome deliberately. Maria’s desperation is valuable. Her precarity is profitable. Her fear is functional.

She’s desperate enough to keep working despite being underpaid. Precarious enough to accept exploitation. Scared enough to leave the hospital with a blocked artery rather than accumulate debt.

The system needs people like Maria. Needs people desperate enough to choose death over debt.

This is not a broken system. This is a system working exactly as designed.

I need to talk about voting because people keep telling me that voting is the solution.

Vote. I vote in every election. I will vote Democratic until I die because Republicans are actively, gleefully making things worse.

But understand what voting can and cannot do.

Voting is not how change happens. Voting is how you ratify change that already happened through organizing, striking, disrupting, making business as usual impossible.

Every expansion of rights came from people making the system ungovernable until power conceded. Labor rights. Civil rights. Women’s rights. Every single one.

Then,only then,did voting matter.

But voting without organizing is just choosing which face will manage your decline.

Patricia understands this better than I do.

“The Democrats are better,” she says. “Marginally better. They’ll throw you a rope while Republicans push you underwater. But neither party is going to dismantle the system that requires your drowning. So we vote for Democrats to buy time. And we organize to change what’s possible. Both.”

So what do we do?

Patricia and I have been having this conversation for months. Since her heart attack. Since the bill. Since Maria left the hospital. Since she came home and couldn’t pretend anymore that working within the system was enough.

Here’s what we’ve figured out:

Stop using their language.

Stop calling it “dysfunction.” Call it design.

Stop calling it “broken.” Call it working.

Stop calling demands for basic dignity “radical.” Call them baseline requirements.

When we use their language, we accept their frame. When we call healthcare “broken,” we imply it’s trying to help and failing. When we call it “working,” we can start asking: working for whom?

Tell the truth.

The system is working as designed. Our comfort is built on someone else’s suffering. We are complicit. All of us who are comfortable.

The question is what we do from there.

Patricia and I benefited from this system. My father’s real estate wealth. Our good insurance. Our ability to afford $437,000 if we had to.

That comfort came from somewhere. Came from someone. Came from a system designed to ensure some people suffer so other people can be comfortable.

We can pretend we don’t know this. Or we can tell the truth.

Organize.

Not just vote,though vote,but organize.

Patricia and I aren’t going to organize unions. We’re old. But we can organize support for people who are organizing.

We can show up with resources. We can use our stability to support people who can’t risk resistance alone. We can be the net that lets other people take risks.

We can fund mutual aid. We can show up at protests. We can use our professional positions to speak up. We can make people uncomfortable.

That’s the point. Making people uncomfortable.

Accept discomfort.

This will cost something.

It’s already costing us things. Friends who don’t want to hear it. Family who thinks we’ve gone radical. Social standing. The comfort of not knowing. The comfort of not acting.

The question is whether the cost of resistance is greater than the cost of complicity.

Patricia and I decided it’s not.

Use your resources.

We have resources. Time, money, stability.

Fund organizing. Fund mutual aid. Fund bail funds. Fund strikes.

Show up physically when people need bodies and numbers.

Use what you have for something other than protecting your own comfort.

Build alternatives.

Support structures that meet needs outside market logic.

Worker cooperatives. Community land trusts. Mutual aid networks. Free clinics. Food banks that aren’t just charity but mutual support.

We can’t vote our way out of this. We need alternative structures that can survive when this system collapses.

And it will collapse. Either from climate catastrophe or internal contradictions.

We need alternatives ready.

Patricia came back into the kitchen later that night.

“You’re going to make people angry,” she said.

“At me or at the system?”

“Both. But Tom,people need hope. If you just tell them everything is designed to hurt them, they’ll give up.”

“So what do I say?”

“Tell them the truth. That the system is working as designed. That it’s designed to extract profit from suffering. That we’re complicit.”

She took a drink.

“But also tell them we have more power than we know. That the system works only as long as we keep participating. That we can build something different.”

“Can we?”

“I don’t know. But we have to try. Because I can’t keep watching people die for profit. I can’t keep watching Maria walk out with a blocked artery. I can’t keep being part of the machine.”

I look through the window now. I check if Patricia’s still standing.

Sometimes she waves.

Sometimes I wave back.

Sometimes we just look at each other and understand that we almost lost this. Not to some dramatic catastrophe. To the quiet violence of a system working exactly as designed.

The woman at Walgreens is still out there somewhere. Still rationing insulin. Still slowly dying from corporate profit extraction.

Maria is out there somewhere. Still working her nursing shifts. Still walking around with a blocked artery. Still choosing debt over death because at least debt doesn’t destroy her kids.

I don’t know their stories. Don’t know if they’re okay.

But I know the pharmaceutical executives are fine. The shareholders are fine. The system is fine.

Patricia is recovering. We can afford her medications. We’re fine.

And that’s the problem.

The system that charged us $437,000 to save Patricia is the same system that let the woman at Walgreens walk out without insulin. The same system that let Maria walk out with a blocked artery.

Same design. Same function. Same success.

The system works for the people it was designed to serve. We are not those people.

Even comfortable people like us. Even people with good insurance. Even people who can afford the bill.

Because the system that saves you is the same system that bankrupts you for being saved. The same system that requires other people’s death for its profit.

I’m sixty-six years old. I am comfortable. I am complicit.

Patricia is fifty-five. She nearly died. The system saved her and charged us $437,000. We can pay it. Most people couldn’t.

That’s not justice. That’s not healthcare. That’s extraction.

Patricia and I are done being comfortable.

We’re organizing. We’re showing up. We’re using our resources.

Not because we think we’ll win. Because we would rather lose fighting than survive complicit.

Because people are dying right now for profit.

Because the woman at Walgreens is still rationing insulin.

Because Maria is walking around with a blocked artery.

Because Patricia is still going to work every shift watching the machine grind people up.

Because someone has to say: this is not acceptable.

So stop calling it broken.

Call it what it is: a machine designed to extract value from human suffering.

And then decide what you’re going to do about it.

The woman at Walgreens is still rationing insulin.

Maria is still walking around with a blocked artery.

Patricia is still recovering.

The system is still working.

What are you going to do?

If this piece unsettled you, that’s the point. I’m not writing this to decorate the timeline. I’m writing it because people are dying inside a system we’re told is merely “complicated.” Independent writing like this doesn’t survive on algorithms or corporate sponsorship,it survives because readers decide it matters. If you believe these stories need to be told without softening the edges, consider becoming a paid subscriber. Your support keeps me reporting, keeps me writing without compromise, and helps turn anger into something organized and useful. If we’re going to tell the truth about the machine, we’re going to need each other.