Every American knows someone who has stared down a medical bill that looked more like a mortgage than a hospital statement. A spinal surgery can be billed at $180,000. Dental procedures that insurance technically “covers” can still leave families owing $20,000. Even with so-called catastrophic caps, deductibles and coinsurance saddle patients with tens of thousands in obligations. These are not anomalies but the predictable outcome of a system built not on care but on leverage.
A 2019 study in the American Journal of Public Health estimated that 66.5 percent of U.S. bankruptcies cite medical issues as a key contributor. In 2023, the Kaiser Family Foundation reported that more than 100 million people in the United States carry medical debt. These are not marginal cases; they are structural features of the system.
We are told this is a market. In reality, it is a hostage situation. Citizens “choose” insurance the way an abuse victim “chooses” to comply with a partner’s demands: not because they want to, but because refusal means ruin. The weapon is not a pistol at the temple but the unpayable invoice that arrives when life and health are contingent on ransom.
The Everyday Brutality of Debt
According to a 2022 Kaiser Family Foundation survey, 41 percent of adults carry medical or dental debt. More than a third—36 percent—report having postponed or skipped care they needed because they couldn’t pay. That means cancers caught later, heart disease untreated, strokes that could have been prevented. More than 20 million adults owe at least $250 in medical debt, 6 million owe over $5,000, and 3 million owe more than $10,000. One-third say they cut back on food, heating, or rent to keep up. Over 40 percent drained their savings entirely. These aren’t just “unexpected emergencies” either: more than half of this debt comes from routine care—doctor visits, lab tests, prescriptions.
Meanwhile, hospitals file lawsuits against their own patients. The Baltimore Sun reported in 2019 that Johns Hopkins, one of the most prestigious names in American medicine, had sued thousands of local residents for unpaid bills. Most were low-income, many were Black, and some had liens slapped on their homes over debts as low as $1,089. That’s not healing. That’s predation.
The Mental Toll That Explodes Beyond the Individual
Medical debt corrodes the psyche. A 2023 KFF/Commonwealth Fund survey found that adults with debt were more than twice as likely to delay or skip mental-health care. Depression deepens, anxiety metastasizes, despair hardens into resignation. The same survey showed that indebted patients reported double the rates of hopelessness and suicidal ideation compared to those without debt.
And in America, untreated despair doesn’t stay quiet. The CDC has documented that states with the highest unmet care needs also report higher suicide rates. RAND researchers note that untreated mental illness is a contributing factor in violent incidents. The U.S. Secret Service, in its behavioral analyses of mass shootings, has found again and again that perpetrators were often in acute mental-health crisis but cut off from effective care.
Correlation isn’t destiny, but it’s obscene to deny the link: a society that walls off millions from therapy and psychiatric treatment is a society that incubates violence. When counseling is unaffordable, when antidepressants cost more than groceries, when one in three Americans skips essentials like food or utilities to cover health costs, what do you think happens? Pain turns inward—suicide, substance abuse. Or it detonates outward—rage, domestic violence, shootings.
A society that makes survival contingent on ransom also manufactures instability. The gunman at the grocery store is not born in a vacuum. He is the product of an economy that monetizes despair until it explodes.
The Moral Canon Is Unambiguous
The Western tradition is not neutral here. Aquinas declared lex iniusta non est lex—an unjust law is no law at all. Locke and Rousseau tied legitimacy to the social contract; when the state protects private rents instead of life and liberty, the contract is broken. Kant insisted laws must be universalizable. Could you will a world where survival depends on paying tribute to an intermediary? No—the rule collapses under its own absurdity. Mill gave us the harm principle: liberty may only be restrained to prevent harm. Here, liberty is restrained precisely to cause it. Rawls argued that when injustice is grave and lawful channels are blocked, civil disobedience is justified. Well, injustice doesn’t get much graver than being bankrupted for daring to survive.
The canon doesn’t just critique this system—it prescribes the next move: refusal. Not passive, not private, but collective. The abused partner finally says, enough. No more premiums. No more co-pays. No more garnishments, no more debt sentences for an MRI. Stop paying, all at once.
The Consequences of Refusal
If millions withheld payment, insurers would collapse within weeks. Hospitals, hooked on charging two and three times Medicare rates, would face immediate liquidity crises. Washington would have no choice but to act: either build a system that serves the public or preside over chaos.
And yes, there would be chaos. Patients mid-treatment might be harmed. Providers would scramble. But look around—the chaos is already here. A 2023 Gallup–West Health survey found that 91 million Americans—over one-third of adults—cannot afford quality care. Tens of millions skip treatment every year. Two-thirds of bankruptcies cite medical bills. Life expectancy in the U.S. is 76 years, five or six years shorter than in every peer nation that spends far less. Stability? That’s the illusion. Collapse is the daily reality.
So when critics fret about disorder if people stop paying, they miss the point: the disorder is now. The refusal would only make visible what the system already is—a corpse propped up by fear.
The Enlightenment Inheritance
The Enlightenment was never about obedience for its own sake. It was about reason, conscience, and the insistence that laws derive legitimacy from justice. The citizen of conscience was not meant to bow to arbitrary coercion but to stand against it, even when it came dressed in statute. To resist coercion for profit in the realm of survival goods is not to reject society; it is to recall society to its own principles.
Measured against that inheritance, those who resist extortionate structures are not criminals but exemplars. They dramatize the gap between what law is and what law ought to be.
The Fork in the Road
Some will brand this anarchism. But what’s anarchic is pretending we can call ourselves heirs of the Enlightenment while obeying extortion as if it were law. Hobbes wanted order, but even he said the sovereign’s first duty was preservation of life. Kant’s maxim demands universality: refusal together is the only rule that passes. Utilitarians weigh harm against happiness—by that measure, this system is indefensible.
So here we are. Either we reform it lawfully—enforce price caps with teeth, build a public option, guarantee universal care—or one day people will realize en masse they can simply say no. The West already told us where the line was. We’ve crossed it. The only question left is whether we have the backbone to follow through.
And this, ladies and gentlemen of the public, is why Luigi should be exonerated.