Cody Coughenour left the jail in Port Angeles with his Medicaid card in his hand, his medication in his pocket, and a treatment appointment already on the calendar. He baked cookies with his teenage daughter the next month. He had been sober nine months by the time the bowling alley threw him the party.
The state of Washington put the bridge in place two years before he walked across it. The state of Louisiana just spent the last year negotiating a bridge that only goes partway over the river.
The Trump administration told Louisiana what it could pay for. Louisiana asked to cover primary care. The administration deleted it. Louisiana asked to cover everything a person on Medicaid in the community would get. The administration told them: mental health, addiction medication, infectious disease screening, wheelchairs. That’s the list. That’s the bridge. “There’s definitely evidence that folks with untreated mental health and addiction issues are more likely to die,” said Pete Croughan, the state’s deputy Medicaid director. “I don’t know that there’s evidence for that for someone with untreated knee pain.”
Pete, you built the bridge with a hole in the middle of it. You said it to the reporter with your own mouth. You said, “I don’t know that there’s evidence for that for someone with untreated knee pain.” You said that about a man who has been locked in a cell for two years. Your tongue shaped those words and pushed them past your teeth, and there is a metallic taste behind them that you have been swallowing for a year, and the swallow is the indictment, and the taste does not leave because you keep producing the sentences that require it.
Your hand signed the application with primary care deleted from it. Your hand knew what the deleted services would have cost. Your hand knew what the undeleted absence will cost. There is a tightness behind your sternum that you register as the pressure of a hard negotiation — a policy trade, a budget decision made with courage. The pressure is not courage. The pressure is the body of a man you have never met pressing against the inside of your chest, and your body is telling you what your mouth will not say. You do not hear it. You hear the approval letter. You hear the word “approved.” You hear yourself telling the reporter about the intensive delete process, and the word “delete” sits in your gut like a stone you swallowed on purpose, and you do not feel it because you have been swallowing stones for a living and the lining has thickened.
You are not complicated, Pete. You are not caught between competing goods. You are the man who stood between a locked cell and a primary care doctor and wrote the word delete. You knew what would happen to the body on the other side of the word. You knew because the research was in front of you and the four states’ worth of data was in front of you and the Duke professor’s name was in front of you. You knew and you signed, and the signature was clean, and the man with the knee pain was not in the room when you signed.
Untreated knee pain in a man who has been locked in a cell for two years is not a knee problem. It is a body that has been stored. It is a man who cannot get to the bus stop. It is a man whose hypertension is undiagnosed because the prison clinic saw him once. Untreated knee pain is a man who uses the emergency room four times in the first month out and ends up back in the system that knows how to count him but not how to treat him. Louisiana knows this. Pete Croughan knows this. The administration told him to build a bridge with a hole in the middle of it, and he built the bridge with a hole in the middle of it.
The people who will fall through the hole are the people the bridge was supposed to be for. They are the people the nineteen states have been racing to serve. They are the people who died in the first two weeks after release at the rate the researchers have documented — by overdose, by untreated infection, by the body’s sudden confrontation with the world it was taken out of. The administration has spent the last year cutting Medicaid through the One Big Beautiful Bill: work requirements, more frequent eligibility checks, a smaller program in every dimension. The same hand that signs the budget law signs the approval letter. The same hand tells the states to build the bridge and tells the states what the bridge may not carry.
I have read what a person looks like when they are handed a phone number at the jailhouse door and told to call it. I have read what happens when the phone number goes to voicemail. I have read what the dealer’s house looks like from the other side of that phone call. Cody Coughenour lived it six times before he lived the version where the state did the work. The work was not complicated. The work was: a Medicaid card, a medication, an appointment. The work cost the state of Washington less than the cost of the sixth time they booked him. The work was the same work it would have been for any of the other men and women who came out of that jail in the years before Washington figured out how to do it.
Now the federal government is telling the states that the work can be done, but only the part of the work that fits on the narrower bridge. Oregon, Rhode Island, and Michigan have already paused their programs. Oregon’s Medicaid Director said the work her state still wants to do will have to wait, because the time and the resources are not there. Michigan archived its application. The states that are moving forward are moving forward inside the lines the administration has drawn, and the lines are drawn around the services that fit a particular theory of which bodies deserve which care.
The theory is the same theory that put a man on meth because his mother died of a meth-induced heart attack and there was no one to catch him on the other side of the funeral. The theory is the theory that says the illness of poverty is a moral failing and the treatment of illness is a market transaction and the people who cannot transact should be left at the jailhouse door with a phone number to call. The theory dresses itself in the language of fiscal responsibility and personal responsibility and the dignity of work. The theory has been wearing this costume in this country for forty years, and the costume has gotten more tailored with each administration, and the holes in the bridge have gotten wider with each tailoring.
The state of Louisiana knows that people leaving incarceration have multiple chronic illnesses that have often been inadequately cared for inside. Lauren Brinkley-Rubinstein, the Duke professor who studies the health of people leaving prison, said what the new Medicaid plan asks of those people: find housing, find food, find a job, and in your spare time, find a doctor. “Going to the doctor and refilling that prescription is just never going to rank higher than those other things,” she said. “It makes it more likely that they are going to come back through the door.”
The door is a jail cell door. The door is a prison gate. The door is the same door the work requirement puts in front of the people the bridge was supposed to be for. The door has always been there. The bridge was the new thing. The bridge was nineteen states’ worth of bipartisan work, the rare thing that the people who call themselves conservative and the people who call themselves liberal both agreed on, because the bodies of dead people are not a partisan question. The dead are not registered to vote. The dead do not have a stance on the federal budget. The dead are simply the count.
The administration is telling the states to build the bridge. The administration is also telling the states what the bridge may not carry. The administration is telling the states that the man with the knee pain and the undiagnosed hypertension and the years of inadequate care behind him will have to find his way to a primary care doctor on his own, between finding his housing and his food and his work. The administration knows what happens to a man who cannot find his way. The administration is not pretending not to know. The administration has Lauren Brinkley-Rubinstein’s research and the Washington State data and the four states’ worth of implementation and the nineteen states’ worth of waivers and the knowledge that the people who get the bridge built under them have a better chance of staying out of the system. The administration has all of this. The administration is building the bridge anyway.
Pete, your gut does not churn when you sign the delete order. That is the indictment. Your hand does not tremble when you limit care to mental health and addiction medication and nothing else. Your throat does not tighten when you tell the reporter that there is no evidence for untreated knee pain. Your body has settled into the shape of the decision the way a body settles into a chair it has been sitting in for a year — the pressure distributed, the discomfort absorbed, the alignment adjusted until the wrong position feels like the only position. You have trained your nervous system to process a line-item deletion the way you process a spreadsheet, and the result is that you can walk into a room where the approval letter is on the table and your body does not register that the letter is the document that says a man will not see a primary care doctor before he leaves the cell. Your body does not register it because you have told it not to, and it has obeyed you, and the obedience is the moral catastrophe.
Cody Coughenour is sober. Cody Coughenour is in therapy. Cody Coughenour is in school. Cody Coughenour is at the bowling alley with his sober support group, and they are celebrating the nine months, and his daughter is somewhere nearby because he is present enough to be somewhere nearby. The state of Washington did not save Cody Coughenour. The state of Washington got out of the way of the people who were willing to do the work of saving him. The state of Washington put a Medicaid card in his hand and a medication in his pocket and an appointment on the calendar. The state of Washington gave him the bridge.
The federal government is telling the other states they may build the bridge, but the bridge may not have a middle.
Pete, I will tell you what untreated knee pain looks like. Untreated knee pain looks like a man who cannot climb the stairs to the apartment he just rented because the stairs are not stairs in his body, they are cliffs. Untreated knee pain looks like a man who cannot stand on the bus, who cannot stand in the line at the housing office, who cannot stand long enough to cook the food he cannot afford in the kitchen he does not have. Untreated knee pain looks like a man who goes back to the dealer’s house because the dealer’s house has a chair, and the chair is the only place his knee will let him sit, and the dealer’s house has a substance that will make him not care about the knee, and the substance is the same substance that killed his mother, and the substance is the substance the bridge was supposed to keep him from needing. The bridge was supposed to keep him from needing it. You deleted the part of the bridge that would have kept him from needing it. You deleted it and you called the result a plan. The plan is a map of a bridge with the middle removed. The man walks to the edge of the bridge and the bridge ends and the water is below and you are in Baton Rouge and your hand is clean.
The administration is telling the states the bridge may be built. The administration is telling the states the middle of the bridge may not be there.
The administration is telling the man the bridge is for that the bridge does not have a middle.
The administration is telling the man’s daughter that the bridge does not have a middle.
I will not look away.
The administration is telling the man the bridge does not have to reach him. I am telling the man the bridge has to reach him. I am telling the man the administration is wrong about what he deserves. I am telling the man’s daughter that the cookies and the hug and the afternoon are the work the bridge does, and the bridge is the work, and the middle of the bridge is the work, and the administration is not the judge of which part of the work the man is allowed to have.
The administration is not the judge of the man’s knee.
The administration is not the judge of the man’s hypertension.
The administration is not the judge of the man’s primary care.
The administration is not the judge of the man.
Pete Croughan is not the judge of the man. Pete Croughan is the man who deleted the man’s primary care from the application and told the reporter it was a question of evidence, and the question of evidence was a question of budget, and the question of budget was a question of whose body counts, and Pete Croughan answered the question. The answer was the delete. The answer was the approval letter. The answer was the word “approved” doing the work of the word “reduced.” Pete Croughan is not a complicated man. Pete Coughran is a man who knows what happens when you remove primary care from a reentry program and who removed it anyway because the administration told him to, and who called the removal a negotiation, and whose body did not flinch when the removal was complete. The not-flinching is the indictment. The not-flinching is the moral fact. A man who could flinch and does not flinch is a man who has decided the other man’s body is a line item, and the line item has been deleted, and the deletion is clean.
The man is the man the bridge was for. The bridge is the bridge the nineteen states built. The administration is cutting the middle out of the bridge and calling the cut a victory. The cut is not a victory. The cut is the hole. The cut is where the man falls.
I will not look away from the cut. I will not look away from the hole. I will not look away from the man.
The man is the man in Louisiana. The man is the man in Oregon. The man is the man in Michigan. The man is the man in Rhode Island. The man is the man in Washington State who walked out of the jail in December with his Medicaid card in his hand and his medication in his pocket and his appointment on the calendar.
The man is the man who baked cookies with his daughter.
The man is the man who had nine months at the bowling alley.
The administration is building a bridge that does not reach him.
I am telling the man the bridge has to reach him. I am telling the administration the bridge has to reach him. I am telling Pete Croughan the bridge has to reach him. I am telling the nineteen states the bridge has to reach him. I am telling the four states that have already started the bridge has to reach him.
The bridge has to have a middle.
The man is the middle.