Hypochondria isn’t what people think it is, and the U.S. medical system makes it worse.

Trigger warning: discusses panic attacks and health problems. Use caution if you’re sensitive to health anxiety or panic.  

I suffer from health anxiety, often called hypochondria. In addition to cyclothymia (a milder variant of bipolar disorder) and panic attacks, I suffer from an intense fear of health problems. In fact, almost all of my panic attacks are related to obsessive health-related anxieties.

Oddly, despite my extreme phobia of sickness, I fear death very little. I’m a Buddhist and believe in reincarnation, so I believe that I have died millions of times (although I don’t remember them) and am therefore “dead” already, and it ain’t so bad. Death doesn’t scare me. I hope that it won’t be painful (the period leading up to it probably will be; I’m realistic) and I look forward to the event itself. Getting sick scares the shit out of me, not because of the pain or risk of death or inconvenience, but just due to the sheer humiliation of it.

Most people use “hypochondriac” to describe a person who is overly dramatic, needy, or attention-seeking when it comes to matters of health. That’s not me. When a panic attack starts throwing bizarre symptoms and I start belching, smacking my stomach to prevent (a completely imagined and probably medically impossible) diaphragmatic spasm that I fear might stop my breathing and kill me, ineffectively massaging my neck and shoulder muscles, or pacing the room, I really wish others wouldn’t take notice. It’s fucking embarrassing. It’s stupid. The stereotypical hypochondriac constantly believes that he is sick. Not so, at least not in my case. Cognitively, I know that (with high probability) I am not sick. I eat well, don’t drink or use drugs, and I exercise regularly. I have also (unfortunately) had enough people close to me die that I realize that bodies usually break down slowly– House be damned– and never for no reason– House gets that right– so I can ratiocinate that the slight pain at my ribcage isn’t actual angina, which I am almost certainly not having because I am a 31-year-old in good shape and no family history of early heart disease. I know that, cognitively. But the thing about obsession is that it trumps cognition. You can know that you’re OK and that the panic attack will end once the meds kick in, and you are basically lucid, but intrusive thoughts about ambulances and hospitals and uncaring medical professionals and life-wrecking bills and losing jobs and relationships can’t be stopped. They build up until you have detached from reality and your body (or, at least, the signals you are getting from it, with probable neurological wire-crossings turning mild discomfort into more dreadful sensations) begins to go haywire.

Panic disorder is the ultimate troll. It is almost hallucinatory in its ability to throw bizarre physical symptoms at a person. I won’t list them, because I don’t want to give panic fuel to someone else who might be reading this, but to name one of the more bizarre ones: phantom smells. (I name it because it’s actually pretty funny, moreso than thinking today is the day you discover that you have adult-onset diabetes because of a dry throat.) What the fuck is up with that phantom smell shit? If God or “the Universe” is testing me or sending a message, what the hell does the smell of fucking relish have to do with it? I think the only other disease (than panic disorder) that causes phantom smells is brain tumor, and I’ve had the problem for 7 years and I’m still alive, so I’m pretty sure it’s not the latter. Fucking relish. Anyway…

One TV character who is shaping up, for the record, to be my favorite mentally ill character is Chuck McGill on Better Call Saul. It’s a compassionate depiction, but a realistic one. He’s not a drooling mental patient or an invalid or a psychotic murderer. He has a crippling anxiety disorder (far more intrusive than mine) which is a fear of electricity, and has had to leave his high-paying job as a law partner because of it, but (as of Episode 2) he’s lucid, smart, morally decent, and likable on all counts. In the mentally ill population, he’s a “silent majority” example: one who has a stigmatized illness, but with full intelligence and moral decency intact. Admittedly, “full intelligence and moral decency intact” is not how most people view mental illness; that is, largely, because most people associate mental illness with the most visible and extreme examples: (1) people who are so far gone that they can’t function in society at all, and (2) substance abusers, who are an atypical set for a number of reasons. I’d actually guess that the “silent majority”, even with stigmatized illnesses like bipolar disorder, is well over 90 percent. The stereotypical Hollywood manic-depressive goes on spending sprees, becomes sexually promiscuous, does a bunch of drugs, or gets into fistfights. When I go hypomanic I can be found at 1:00 am… reading. Or writing. Or coding. I call this the “cerebral subtype” and while it has its dangers (sleep deprivation can exacerbate hypomania) it does not make a person like me morally dissolute. It makes me… slightly groggy the next day.

The general population, in my view, doesn’t like to accept the reality about “mental illness”, which is the term we use for neurological diseases whose symptoms involve cognition. First, these are mostly “boring” health problems like all the other ones, which present challenges and can be extremely painful and disruptive, but rarely change the moral character of a person. People wouldn’t deign to ask whether a person with migraines or diabetes “can handle” a difficult job, but that’s a common question asked of people who’ve dealt with anxiety. These “mental” illnesses don’t send a person on a one-way journey into insane lal-a tinfoil land. They don’t, in general, make a person “crazy” in the sense of being impulsive, delusional, or dangerous. They are malfunctions in an organ that, while extremely powerful and resilient, exists in a stew of complex organic chemicals and operates according to an electrical protocol that we just barely understand. Most mentally ill people (whether we’re talking about bipolar disorder, depression, or anxiety) are surprisingly “normal”: again, the silent majority. Why is there a resistance to this idea, in the mainstream? Because, in general, people don’t want to believe that painful things won’t happen to them. “If I don’t smoke, I won’t get lung cancer.” “If I take 27 vitamin pills per day, I’ll die at age 109 in my sleep.” “If I’m not a crazy person, I’ll never have a life-altering depressive episode.” Sorry, but all of those beliefs are false. Healthy choices alter the probabilities quite favorably, and most people who reach age 25 without a mental health issue are in the clear… but there are no guarantees.

This is why (as of Episode 2) I find Chuck McGill so interesting. He’s not “crazy”. Everything he says has value. He’s an intelligent and good man. He also happens to suffer from a severe psychiatric illness. It seems paradoxical in light of our expectation that mentally ill people be “crazy” (in the drooling, “mental patient” sort of way) but it’s actually pretty normal. I don’t know how Better Call Saul intends to develop him, but this is one of the more honest portrayals of mental illness that I’ve encountered. The tragedy of these diseases (in their most severe forms; mine is relatively mild) is that they afflict normal people, not “crazy” ones. There is such a thing as “crazy”, but it’s mostly orthogonal to mental illness. Religiously motivated suicide bombers are crazy, but I would wager the guess that quite a large number of them suffer from no biological mental illness and that, at the top of terrorist organizations, people with mental illness (except psychopathy) are very uncommon. Evil is real and not the same thing as mental illness.

Back to panic: a true panic attack– and I’m not talking about the low-level yuppie anxiety attacks that come from a deadline and too much caffeine– is a venture into something like “crazy”, but paradoxical in that the panicking person is, in fact, terrifyingly lucid. A person with that much adrenaline is, in some ways, in peak physical function (despite mental distress). Facing off against a smilodon, one would want that “fight-or-flight” response. It’s when it’s triggered without cause that we call it “a panic attack”, because it’s so pathological against the backdrop of modern life, in which mortal danger is rare but social protocols must be followed. Acute panic tends to last no more than three minutes, although the fatigue and anxiety that can exist afterward can spawn another wave of panic, leading into an episode that can last (at worst) two or more hours. Panic is almost hallucinatory; it wouldn’t be inaccurate to describe it as a (short-lived) bad trip on a drug that one didn’t voluntarily take, and never really wanted. It is almost admirably creative in its ability to take mild discomfort (which is inevitable with any anxiety disorder) and transform it, wholly in the mind, into acute danger. A tight shoulder muscle becomes “chest pain”, and cold extremities become “imminent hypothermia”, and the fatigue that sets in after 20 minutes of panic (if the attack hasn’t abated by then, which it usually has) becomes a threat of fainting (which any proper hypochondriac knows by the medical term, “syncope”.) I know that this sounds fucking ridiculous. Sufferers of the disease would agree; it is. But the nature of a panic attack is that baseless and undefined fear reaches such a crescendo that it will (for a minute or two) override sensible cognition. That extreme, biologically-induced fear needs to crystallize around something and it is usually something in the body– that machine that (usually) works so well running on its own, for billion-year-old reasons that science is just starting to understand, and that it is impossible for us, on a second-by-second basis, to consciously manage.

The popular image of a hypochondriac is of someone who either convinces himself that he is sick, or feigns illness because he enjoys attention and sympathy. An actual hypochondriac is the opposite. First, we have no incentive to pretend and, if anything, we downplay our suffering. It’s fucking humiliating, and it would depress the shit out of most people, and my desire with regard to negative moods is anti-reproductive; I combat them by making efforts not to spread them. It’s the one thing I can do. Depression and anxiety are not physically contagious and my job is to prevent social contagion. If there’s any danger of error in a hypochondriac, it’s that we may (later in life, when life-threatening physical illnesses are more common) misinterpret dangerous health problems as just panic attacks and not seek care. Second, we generally do not frequent ERs when we have health-anxiety-induced panic attacks. Contrary to the image of a hypochondriac as someone who is stupidly or delusionally convinced of an illness he doesn’t have, we know cognitively that we are probably fine, but are overwhelmed by the intense physical symptoms and racing, uncontrollable negative thoughts. When you misinterpret (due to crossed neurological wires, not stupidity) neck tension as the throat closing up, you will fucking panic. (In fact, your breathing is fine. But you feel like you are choking and it is going to freak you out.) Going to an ER during a panic attack doesn’t help: you’ll spend four hours surrounded by hospital staff who resent you (“another one of these rich white pieces of shit ‘freaking out’ after a hard day at work”) and you’ll see people who are suffering from painful and more severe health issues (panic fuel) than the one you’re having… only not to get the medical attention you need because (a) ERs are intended for life-threatening conditions rather than subjectively terrifying ones and (b) ER doctors can’t be sure that you’re not a drug-seeker and are therefore conservative (for understandable reasons) when it comes to dispensing medicine. I’ve been to an ER twice for a panic attack (more on that, later) and it turned one of the worst experiences of my life into… an even worster experience. And yes, I made up the word “worster” because some things are so shitty that they entitle a person who has experienced them to make up words. Third and most importantly, we do not “freak out” because we want to get out of work, win sympathy, or otherwise gain favor from other people. First of all, that doesn’t work, especially not with stigmatized conditions. Most of us hypochondriacs are type-A control freaks (after all, hypochondria derives in part from our inability to know or control the operation of our own bodies) who, if anything, love to work a little bit too much. Trust me on this: I enjoy my job, I’m good at it, and I would absolutely love to be able to work 80 hours per week (not to say that I would work that much, but I’d like to have the ability) and not lose a single minute, ever, to anxiety or panic.

That’s enough of this shit, but this rant wouldn’t be complete without an indictment. One of the most important things to understand about mental illness is that, in terms of origin, it’s usually “no one’s fault”. My parents didn’t cause this; they were great. Nor is it my fault, really. I didn’t ask to have it. Nor is the fault of society or past relationships and jobs or present ones… for the most part. Based on genetics, it’s almost a guarantee that a person of my makeup would have struggles no matter what circumstances he landed in. It’s an interesting trade: 4 standard deviations of this fetishized quantity called “intelligence” in exchange for losing 5% of your time to painful mood and anxiety disorders. I’m not bitter about the deal, even though I didn’t make it voluntarily. To be honest, I’d probably make it again. I’m glad I’m me. It really sucks some of the time, but isn’t that true for everyone?

No one’s at fault for the fact that I’ve had panic attacks, but I’m going to throw some stones at those who’ve made the condition worse. The U.S. medical system, to put it bluntly, can die in a fucking taint fire. I’ve had good doctors and bad ones, and I continue to see the good ones despite my acquired doctor-phobia because I’m rational, but the system itself is a moral disaster.

My first panic attack came in 2008. It was scary, bizarre, and confusing. Though many come with warning and a build-up, this one hid immediately. This sudden and absolutely terrifying “mystery” health problem involved vomiting, tunnel vision, apprehension and shaking. It came on at 2:37 pm. I tried to drink water and it was physically impossible to swallow. At 2:41 pm, I was white as a ghost but lucid. At 2:46 I began vomiting and screaming (in front of work colleagues). At 2:50 I was fine. Around 3:00 an ambulance was called and I arrived at an ER at 3:15. I saw a lot of people who were suffering, and worried about that being my immediate future, so I had a couple of anxiety waves (none reaching the level of the original one). Around 7:15, I got about 72 seconds of contact with a doctor who diagnosed it as a panic attack. So, that is what a fucking panic attack is. See, I’d thought I’d had “panic attacks” before but, in retrospect, those were mild anxiety attacks. The difference is in degree. If anxiety is sugar, panic is coke.

The second one was worse. The first panic attack is scary but might just be a one-off. The second comes with the “yep, I’m now going to be a psychiatric cripple for a while” realization. It came a week later. Most of my panic attacks come in the late afternoon, but this one came around 1:00 in the morning. It made sleep impossible (exacerbating the illness) and rolled along for about 22 hours. A typical panic episode has 3-4 peaks spread out over 15-30 minutes. This one must’ve had 100 peaks. I was exhausted, dry-heaving, unable to keep food down. At random times during that day, my vision would suddenly go blurry, or I’d have an intense whole-body tingling, or I’d feel weightless (not in a good way, but like one is leaving the planet forever but will never die). Finally, at 6:00pm that evening, the girl I was living with forced me to go to the ER. I arrived at 6:38pm.

I was living in Williamsburg. I like Brooklyn but dislike Williamsburg: there is an intense negative energy there. It was full of young people who were arrogant, flaky, and full of bullshit Burning Man drug-wisdom that can combine with the “openness” of one’s mind upon acquiring a new disability to make you more scared of what’s going on than you should be. (“You’re entering a new spiritual plane!” vs. “You’ve developed a treatable condition and, if you take your meds and pursue cognitive-behavior therapy, you’ll be able to hold down a job and function normally within 6-12 months.”) I bring this up because, while Williamsburg is an affluent part of Brooklyn, the hospital that we chose to go to was… not. It was in the ghetto, and it was badly run.

I learned this later: when you present with a panic attack, physicians are supposed to run a battery of tests to rule out other conditions that can produce similar symptoms. This is good for two reasons. First, although they are rare in 24-year-old males, there are far more serious health conditions with similar symptoms that ought to be excluded. Second, it lets you (as patient) know that you are objectively healthy. Panic attacks are not nearly as scary when you are able to convince yourself, 100%, that “just panic” is what they are. If every panic attack felt like “just a panic attack” they wouldn’t be scary. It’s their weird-ass inventiveness at coming up with new symptoms that makes them terrifying. Anyway, that didn’t happen at my first ER visit, so I demanded it at my second. I went to triage and said, perhaps with some exhaustion due to 17 hours of mental anguish, “I know that I’m just having a panic attack but I want you to run all the requisite diagnostic tests and tell me what the fuck I have to do to fix my fucking brain.” I may have been a bit pushy, given the state that I was in. The staffer didn’t like this. He didn’t like me. I was a white kid living in Williamsburg with a $100+k-per-year job at age 24. He probably assumed that I had blitzed my brain on designer drugs (I hadn’t). He dumped me in a psychiatric ER. Now that is a place where I never again want to be.

You can leave a regular ER if the wait time is unreasonable, but not in the psychiatric section. Once you’re in, you can’t get out. They take your shoelaces, they take your money, and you can’t be discharged until you’ve seen a doctor (which may be, as it was in my case, more than 6 hours later). There was a loud television, and what struck me in the hypersensitivity of acute panic was how negative the content was: commercials designed to exploit envy and insecurity, some episode of some shit about teenagers being horrible to each other due to boredom. Most people (including myself, in normal moods) can be exposed to that low-level negativity and not be affected by it; it’s just crass entertainment. But it is fucking irresponsible to blast that shit, at full volume, into a crowded psychiatric ER with 14 people and 12 chairs. Most people in psychiatric ERs are recovering from panic attacks (and they are probably one of the worst places to recover from anything) and hypersensitive and should not jostled with the negativity of the world. I mean, for fuck’s sake… pretend you actually care about these people instead of just wanting to drown them out with TV noise.

During that six hours, I heard a number of screaming matches between staff and patients, and while one patient stood out as particularly loud and pugnacious, many of them did not deserve the harsh treatment they got. I, for my part, was treated well because I was able to gain the presence of mind to learn the rules and follow them. Sit down (on the floor, because there weren’t enough chairs) and don’t scream or piss anyone off. Be polite when you need to use the bathroom. Definitely don’t say, “I could get Xanax on the street instead of waiting for you assholes.” (The woman who screamed out that line must’ve added a few hours to her wait. Also, you’ll never get a benzo at an ER, even if you actually need one. Also, there’s a cop standing right there at the door, and while he does have better things to do than give a shit about such things being said, show some respect for the law.) I followed the rules, put up with my six-hour wait, tried to read although it was impossible to concentrate, and watched people with far more serious mental health issues suffer and (because of my own state) the most prominent thought was, and I’m ashamed of this now, “I hope that’s not my future.” Turned out, it wasn’t. But I’ll get there.

I got to see a doctor (the one doctor, on a Monday) around 1:00 in the morning. For all the horseshit of that ER and hospital, he was pretty good. He was surprised that I ended up in a psychiatric ER (and apologized for the fact) and he explained to me the physiology of panic attacks and, while he couldn’t prescribe, he gave me a referral.

There’s one more bit of the story that I have to tell. A month later, I went to a specialist for something else, and he discovered that it wasn’t a “phantom” health problem (or hypochondria) that was triggering the panic attacks. At least, it wasn’t then. I’m now at the point where just reading about a disease can give me a panic attack, but at that time, I had a real health issue. The difficulties I’d been having with breathing and swallowing were caused by a bacterial plaque that had formed in my throat after a bout of flu (that I, being stupid and macho and 24, tried to work through) from which I hadn’t properly recovered. The chest pains that I’d been having were LPRD/GERD (acid reflux) triggered by flakes of the plaque breaking off and fucking up my guts. The derealization and hallucination I’d been experiencing were not a brain tumor but typical of high-level panic attacks (thankfully, I rarely have them now.) Once discovered, that problem was easy enough to cure… but I spent a month with a giant bacterial plaque in my throat. I think that even normal people would get panic attacks after having a nasty motherfucker like that living inside them. But I digress.

So why do I indict the American medical system? From my two ER visits, I learned (perhaps in error, because I don’t think that all ERs are bad; I’ve just never met a good one) that emergency rooms will resent and ignore me. This is fine, because an ER is a terrible place to go during a panic attack, and if I ever have a real ER-worthy condition, the odds are that I won’t be conscious. I was eventually able to find good doctors (a psychiatrist for the panic, which persisted even after the throat condition was cured; and an ENT in Chinatown who managed to figure out what was actually wrong with me, physically speaking) but I had to seek out the specialists and hope that my insurance would cover the visits. I was my own Dr. House. The worst bit was the nightmare of insurance. Let me put it in no uncertain terms: U.S. health insurance is a fucking scam, and while “Obamacare” (PPACA) has improved the situation, the basic facts of it remain. In a way, health insurance is the most brilliant swindle there is. First, it picks a great target: sick people. When you rob sick people, they’re less likely to fight back or kick your ass or throw a year of life (when many of them have not so many years left) into a lawsuit. The problem with robbing sick people is that most of them don’t have any money, because they tend to be old and unemployed. So they’re soft targets, but with little meat to chew on. Health insurance is brilliant, as far as ignominious crimes go, because it collects premiums while people are well, cash-rich, and generally young… and then denies promised care when (in general) they are too old, sick, and poor to fight back. It’s like a robber with absolutely no sense of ethics discovered time travel! It’s fucking evil, but give credit where credit is due. Health insurance is an amazingly inventive form of theft.

If you’re not from the U.S., you cannot imagine how bad our health care system is. The quality of care when it is delivered is, I would say, spotty. We do have world-class researchers and there are many individual doctors and nurses who are excellent. I wouldn’t take that away from anyone. Our hospitals are depressing and dangerous places where super-bugs breed because our government doesn’t have the spine to disallow the (cruel and needless) abuse of antibiotics in fucking factory meat farms. Relevant to this topic, our billing/insurance system– even if you’re insured, you’re likely to face enormous out-of-pocket costs if you get seriously sick– compounds the stress of illness and has been a contributing factor to thousands of deaths every year. It’s terrible. I’d call it “Third World” but it’s honestly worse. It’s one thing not to have the resources, as the Third World medical systems often do not. It’s another to be rich in resources but to be a greedy fucking asshole. If there is a hell, I’m sure that the architects of the U.S. health insurance system are going to receive punishments that’d make Dante faint.

Health insurance may seem to be an orthogonal, after-the-fact issue when one is talking about panic. In fact, it taps into what, I think, is at the core of panic. What is it that one truly fears during a panic attack? I’ve said this before, and I’m not bullshitting: I don’t fear death. At least, I don’t fear it in the abstract. It will happen to me and, while I would prefer for it to take its time, I am at peace with it, and I think that most people (including most panic sufferers) are. This body will turn into a corpse, I will pass into another state of existence, and (if reincarnation is true) I will re-emerge as a person who will probably never hear the name “Michael O. Church”. To me, the one thing that is most comforting is that death and panic are opposites. Death is an end of this life; we don’t know what follows it, but we know that we ain’t here anymore. It’s impermanence. For a contrast; in panic, there is a fear of permanence or finality or stuckness. It’s not that the suffering (physical symptoms of health problems one does not have) is intolerable, but there is a sensation that they will never end. (Of course, they always end.) Sometimes, there is the fear, “I will die like this.” In fact, panic attacks are non-lethal. I am not a man of steadfast faith, but I feel comfortable in the belief that whatever being dead is like (and, of course, I don’t know what it is like) is quite different from a panic attack, and probably much nicer.

I don’t believe that panic is actually about death. I think that it’s about humiliation and disempowerment and finally abandonment. So let’s talk about those three fears. Are panic attacks humiliating? A little bit, but most people in the vicinity of a person having an attack are not going to have the intense focus on the event that the sufferer does. I’ve had panic attacks in public and I doubt most people remember them. Are they disempowering? They can be, and some people become shut-ins if they get really bad, but the truth is that a person who is  flooded with adrenaline is actually at the peak of his physical power (although he will be utterly exhausted when the adrenaline wears off). Panickers fear “losing control” but the adrenaline’s purpose is to make sure they have total control if any real danger that should present itself (this means there is a loss of non-essential control, and that produces many of panic’s trademark symptoms). As far as disabilities go, I think that panic attacks are one of the less disempowering, unless they become extremely frequent.

So then, let’s talk about abandonment. I think that it’s something that all of us, and even those who seem to be self-reliant badasses, fear. One can hold a cognitive belief that one is owed nothing by others in the world and not suffer for it. Many people, when they acquire disabilities (such as my relatively mild one) attempt to minimize the disability’s impact on others and be as self-supporting as possible. That’s all fine and good. However, I think that we, as humans, have an ancestral terror with regard to abandonment. We’ll be self-reliant as much as we can, but we need to believe that others will care for us if we are suddenly struck down. I think that most people are OK with the concept of eventual death, but the idea of being left to die, when they could be saved, strikes a primal chord. This, of course, gets to why there is, in many, a more bitter hatred toward health insurance companies (who murder by inaction) than there is toward cancer (which, though not a conscious organism, does the actual killing).

Now we have the U.S. medical system (and, most relevantly, these monstrosities that we call insurance companies) in our crosshairs, because abandoning people is what they do. Doctors don’t; if anything, they are eager to save lives whenever possible. But the rest of the system conspires to deny care, push people away, and let sick people die on someone else’s doorstep.

See, it was irritating that I spent 4 hours in an ER, having to wait to be told that my life wasn’t actually in danger. And spending 7 hours in a psychiatric ER (a prison, in essence) when I didn’t need to be there was a pretty miserable ordeal as well. That shit, though, is small potatoes. I’m OK. (It wasn’t that way for this woman, who died of deep vein thrombosis after a 24-hour (!!!) wait in a psychiatric ER’s waiting room). Then I had to deal with billing, and insurance, and insurance run-arounds, and denials of care that were explicitly contrary to law… for years. Having to leave my job, I had to shell out for COBRA only to have basic claims denied for arcane reasons that were clearly illegal. (“What are you going to do, unemployed, sick person? Sue us?”) That was 2008. Luckily, I had the good sense to find physicians who’d accept fair rates, and I ended up OK, but I also knew that if I did develop a life-threatening health problem, I’d be at the mercy of some absolutely horrible organizations.

It was probably 2010 before I recovered to the point of being traditionally employable (and a bit longer before I had the guts to leave the crappy startup I was at) and there is a large class of jobs that is probably out of the question forever. I’m 31 years old and quite functional (as a programmer, I’d say that I prefer to be “purely functional”) but being a hot-shot trader is pretty much out of the cards. Anyway, let’s talk about 2008 and 2009. I took a job at a pre-A startup, knowing that I still wasn’t well enough to deal with an 8-hour day in a typical tech office. (Actually, I’m surprised that normal people can withstand 8 hours in an open-plan office. Noise is one thing, but being visible to so many other people is horrendous. Every worker ought to be entitled to a barrier at his back.) At this startup, I had no health insurance. You know what’s worse than having a hypochondriacal panic attack? Having a hypochondriacal panic attack and knowing that you have no health insurance, which means that all these health problems the mind is inventing could actually lead to disaster. To put it bluntly, the US healthcare system took a period of my life that should have been one of recovery, and made it one of continuing stress and unraveling. It would not surprise me if I were diagnosed with PTSD based both on the period during which I was underinsured and received poor care, and during the panic-onset recovery period (late 2008-2009) during which I was uninsured.

I recovered. The panic attacks are pretty rare now. I have a good job, I’m married, I have two beautiful cats, and I even have decent health insurance– well, I think so; of course, the only way to actually test your health insurance is to become seriously ill– and can access decent doctors for my continuing medical needs, which are relatively low in expense and volatility. I have, for the most part, beaten this motherfucker. That said, I still have the attacks on occasion. Maybe it’ll be a benign heart palpitation or stomach pain that sets it off. Maybe it will be a bad memory pertaining to the dangerously inept medical treatment I received in the past, that spills over into a flashback. These are things that I shouldn’t have to deal with. I am fucking sick of the fucking panic attacks, and I am fucking sick of living in a society that thinks that it is OK for hospitals and insurance companies to take sick people and, out of a level of greed that even the robber barons would consider abhorrent, stress them out and fuck up their lives even further.

I am, and this should be obvious, disappointed by the progress achieved by President Obama on the healthcare front. Did he improve the system, incrementally? Absolutely, but not by enough. Getting rid of “life caps” and shooting down the scam plans was a good thing, no question. That said, health insurers will invent new ways to fuck people over and in 5 years we’ll be back at the same old shit. The system is too rotten to be improved by any incremental means. You can’t transplant new organs into a patient whose body is 85% cancer. At that point, it’s well past over. We need a single-payer or public-option system, and the existing private insurance companies need to die. Right now we have a system in which the doctors work overtime to heal and fix people, but the hospital billing departments and the insurance companies work overtime to stress them out and re-sicken them. It’s ludicrous. It’s like paying one person to dig holes and another to fill them up, but with more severe ethical ramifications because peoples’ health is at stake.

I write this not as a victim of a rather boring (to tell the truth about it) condition, because I am no victim. At my worst, I was no sicker than most people will be at their worst. Instead, I am a courier, and the message is clear: destroy the current, failing, morally execrable system, and build something new.

Why high-deductible medical insurance often doesn’t do what it’s supposed to.

“There was a friend of mine growing up, call him Tom, whose father was a health insurance executive. Once a month or so, he’d come for dinner and sleep over because his Dad was just in a foul mood, would go upstairs, not be able to cook, and not want to talk to anyone. I asked Tom why his dad had so many bad nights, and he’d explain that his father was a health insurance executive. I didn’t get it at first. Finally, when Tom was about 16, I asked him to explain this matter further. What causes his father’s bad nights? Tom laid it out straight: ‘Those are the days when Dad saves a man at work.’ “ — Unknown American origin.

As the medical insurance and healthcare picture in the U.S., despite the best intentions of at least a few left-leaning policymakers, continually gets worse over the decades, it’s becoming common that health insurance plans have high deductibles, sometimes as high as $10,000 for a family if one needs to go “out of network”. Moreover, given that health insurers will just decide not to cover things because some college dropout or failed-into-the-dark-side doctor decides that a treatment is “not medically necessary” (against the word of an actual fucking doctor) or a “lifestyle” treatment, even “out-of-pocket maximums” can’t always be trusted. Being “insured” means less by the day.

All of this said, for young and relatively well-off people, these high-deductible plans with HSAs seem like a good deal. On paper, taking one can be a reasonable bet, and if there were a way guarantee that they covered all medical expenses, I might agree. If you have a few thousand dollars or more in the bank, and you’re not likely to get sick, then you’re probably only giving up a few hundred dollars in expectancy by taking the high-deductible plan. So what goes wrong? What is the unexpected and systemic issue with high-deductible plans?

Libertarians like the idea of high-deductible plans insofar as they encourage patients to respond to economic signals when choosing treatments. While this appears to be a fine idea (on its own terms, that is) on paper, there are a number of issues with it. Free markets work well at solving a large number of pricing problems, but healthcare has extreme time behavior that other markets don’t. An issue that costs $500 to treat now might cost the patient, or society, $100,000 in a year if untreated. Markets work best when short-term signals reflect long-term conditions, and poorly when there’s a severe discrepancy between the two. Second, there’s a huge information asymmetry for patients, who simply don’t know enough to make informed decisions. Most patients would do better to trust their doctors than to try to make every single medical decision for themselves. This means that exposing patients to “price signals” is at best pointless and, at worst, dangerous. Due to the already-mentioned time behavior of most medical problems, by “dangerous” I also mean “expensive”.

What goes wrong with high-deductible plans? It’s not that deductibles are inherently a bad concept. They apply to auto insurance policies and are generally pretty harmless. The problem with high-deductible plans is this: while insurance companies are trypophobia-inducing clusters of assholes, the “good” news is that they’re assholes to hospitals and medical billing departments as much as to patients, and they have leverage, and they twist arms, and they get prices down. The result of this is that medical bills assessed to fully insured people are about a third as high as those assigned to the uninsured. The medical industry has high fixed costs, and no one knows what a service “should” cost, and uninsured or underinsured patients are so unlikely to pay (and, quite often, unable to pay) that billing departments will just plain price gouge. It’s ridiculous and perverse, and it’s questionable whether it should even be legal to set fees after a service is rendered. Hotels, restaurants, and transportation agencies have to set a price before the consumer makes a decision, but hospitals get to make up numbers after the service is rendered, resulting in absurdities like $250 charges for “mucus collection system” (in non-asshole language, a Kleenex). The only check against this are the health insurance bureaucrats. While they’re clearly motivated by corporate greed rather than good intentions, this class of people indirectly benefits policyholders by knocking prices down reducing premiums.

If we accept that insured patients pay medical bills indirectly, then at least the insured patient has an asshole on his side in negotiation with medical billing departments. The insurer will say, “accept this price or you’re ‘out of network’ and will get fewer patients”. As an individual, though, no patient can say “reduce the damn bill or I’ll never get appendicitis in your ER again”.

The problem with high-deductible plans is that, when a young person insured under one gets sick and incurs a mid-sized bill (say, $1500) the insurer has no incentive to engage in the arm-twisting (arm-twisting that is directly responsible for slashing insured patients’ bills by 60 to 80%, and that you will miss dearly, should you have to pay a medical bill directly) that they absolutely would do if they, as insurer, were paying the bill. (This is different if the insured person is frequently sick and likely to overflow the deductible on a regular basis; but until recently, people like that couldn’t even get insurance.) Don’t get me wrong: I’m not pro-arm-twisting in general. I’d like to see doctors and nurses and medical technicians fairly compensated, not driven to the bottom. In fact, I’d much prefer to re-join the First World and replace our rotten system with a public-option or single-payer system. I’m only saying that, as an individual, I’d prefer to have an asshole arm-twister negotiating my bills down rather than not have one.

High deductible health insurance would be a reasonable idea, and appealing to high-income young people like me, if there were some way to guarantee that the insurer would negotiate just as aggressively as if the deductible were zero and the insurer were paying the bill in its entirety. Unfortunately, I am not aware of any way to enforce that.

There is no “next Silicon Valley”, and that’s a good thing.

I recently moved to Chicago and, a couple weeks later, found myself reading this article: Why Chicago Needs to Stop Playing by Silicon Valley’s rules. I agree with it. I also want to speak more generally on “the next Silicon Valley”. It doesn’t exist. The current Silicon Valley is succeeding in some ways ($$$) and failing in others (everything else) but the truth of it is that it’s an aberration. It has as much staying power as the boomtowns surrounding North Dakota oil. Trying to replicate it is like attempting to create one of those ultraheavy chemical elements that lasts for 50 nanoseconds, but less interesting and far less cool.

I’m 31 years old, which is about 96 in Silicon Valley years, and I’ve seen a lot of the country and world, and I’ve come to the conclusion that “the next Silicon Valley” is a doomed ambition because it’s a pretty fucking lame one.

Rather than explain this, I think that a picture really is worth a thousand years here. So let’s look at some inspiring, creatively energetic, cities. These are the sorts of places that bring ordinary people to reach for the extraordinary, instead of the reverse.



New York:



Okay, so now let’s take a look at Silicon Valley.

I think my point is made by these pictures. There is a sense of place in the world’s great cities that just isn’t found at 5700 Technology Park, Suite #3-107, Nimbyvale, CA 94369.

Why no location can electively become “the next Silicon Valley”

I think the pictures above tell the story well. Becoming the next New York or Budapest or Paris or Chicago is a worthy vision, although any city will develop its own identity more quickly and more successfully than it can replicate another. Becoming the next Palo Alto is fucking lame. Now that the cherry orchards are gone, the only thing that the Valley has is money, and “I just want more money” is a pathetic ambition that leads to failure. Money has to come from somewhere, so it’s worthwhile to understand the source of the money and whether a region’s success is replicable (and desirable). Silicon Valley is rich because it’s a focal point for passive capital. This capital, drawn from teachers’ pension funds and university endowments, gets funneled through a machine called “venture capital” that is supposed to throw its money behind the most promising new businesses. Yet for reasons that most would find unclear, those funds tend to be directed toward a small geographic area. Now, the passive capitalists don’t especially care where their money is sent, so long as they get good returns. If the best business decision were to put that most of that money into Northern California, that would be easily accepted by the passive capitalists, even if they live in other places. While an Ohio State Police pension fund might ideally prefer that some of the jobs created by their passive capital be created in Ohio, they’ll gladly see their money deployed whereever it gets the best returns. That means that the extreme concentration of deployment in California would be completely OK– if it were justified by returns on investment. However, venture capital has been an underperforming asset class for years, and there’s no sign that this will change, because VCs are incentivized to optimize for their personal reputations and careers rather than their portfolios, and that favors the behavior we see. With the returns being abysmal, however, perhaps the Palo Alto strategy ain’t working. Perhaps this extreme concentration of passive capital, creating jobs in already-congested places where ever owning a house is extremely improbable for people who do actual work, is pathological.

My sense on the matter is that Silicon Valley is pathological, hypertrophic, and innately dysfunctional. Talent and capital like to concentrate, but not necessarily in that specific way, and not in such heated competition for resources with the existing economic elite (whose values are at odds with those of the most talented people). While it starves the rest of the country of attention and capital, Silicon Valley is past congestion and suffering for it, in terms of traffic and land prices. On paper, it’s set in a beautiful geographic area, and if you can get away from everything created by humans, California actually is quite pretty. That said, 22-year-olds without cars aren’t going to be impressed by Mountain View’s 200-mile radius when everything they actually see on a daily basis is an ugly, suburban shithole that they pay far too much to look at. Talented people do want to be around other talented people, but they prefer diversity in talent, not rows and rows of tech bros (who often aren’t very talented, but that’s another story). Because of talent’s natural draw toward concentration, and given the U.S.’s tendency toward high geographic mobility, I don’t think that this country will ever have more than 15 or 20 serious technology “hubs”– and even that would be a stretch, given that we currently have about five– but I do think that it’s possible to have a distribution that’s better for everyone involved. The current arrangement is bad for “winning” locations like Northern California, bad for the losing geographic areas, and bad for pretty much everyone individually except for extremely wealthy venture capitalists (who benefit from a reduced need to travel) and well-placed landlords.

As it exists, Silicon Valley probably shouldn’t. It’s a boomtown with ugly (and expensive) housing that wasn’t built to last. It has what could be a decent (if sleepy) almost-city in San Francisco, recently destroyed by the unintentional conspiracy of NIMBY natives (who create housing supply problems) and VC-funded new money. It is rich, on paper, and will be for some time. But replicating accident and pathology is a pretty lame strategy when directing the fate of a new place. The causes of Silicon Valley’s richness and (mostly former) excellence are more worthy of study than the superficial factors, like weather or workplace perks or representation in the entertainment industry.

What, then?

While “next Silicon Valley” is a lame ambition, there is something to that geographic region that makes it attractive to talented entrepreneurs. It provides a path to corporate hegemony that, at least by appearance, combines the “cool factor” of starting a business with the low risk of an investment banking or management consulting track. It encourages risk-taking and a superficially cavalier attitude toward failure, which appeals to a certain type of young person who has never failed and who hasn’t learned yet that life has stakes. The Valley has also done a great job of rebranding the corporate experience as something that left-leaning, upper-middle-class young people can swallow. Silicon Valley excelled in technology in the late 20th century; in the early 21st, it has proven itself world-class at marketing. Since brand-making is crucial to success in the sorts of first-mover, red-ocean gambits that VC (increasingly oriented toward attempting to sit inside the natural monopolies that technology sometimes creates, rather than actually building technology) now favors, that’s not surprising.

In business, there seems to be a continuum between low-risk, slow-growing businesses and “rocket ships” that burn up in orbit 95% of the time. There’s also a misperception, that I want to combat, that utter failure of new businesses is the norm. The risk exists, but 90% failure rates (while not uncommon in the Valley) are actually pathological. The actual failure rate is somewhere around 50 percent. In fact, compared to corporate jobs, the failure rate of typical small businesses (as opposed to VC-funded red-ocean gambits) isn’t much worse. Between firings, layoffs, political messes and damaged reputations relegating a person to second-class status, non-promotability, and less-desirable projects, it seems to be a constant that about 50 percent of jobs fail within 5 years. Of course, the range of outcomes is different; starting a business has more personal downside, and more potential gain. If there’s something that ought to be fixed in the process of new-business formation, it’s the amount of financial risk borne by those who don’t use venture capital.

For low-risk businesses that are unlikely to fail, bank loans are available. However, bank funding is a non-starter in launching even the least risky (“lifestyle”) technology companies, because bank loans those tend to require personal liability, which means that you can’t use them for something that might actually fail. Bank loans are great if one wants to capitalize a franchise restaurant or a parking garage, but not suitable for anything that involves making a new product. At the other extreme, there’s VC. The mid-risk, mid-growth range is, however, overlooked. For a business carrying, say, a 20-30% chance of failure and targeting 40% annual growth, there’s no one out there. Why is that?

Venture capital could be just as profitable by investing in mid-risk businesses as it is by throwing into the extreme high-risk pool. After all, if valuations are fair, then there’s just as much profit to be made investing in large companies as small ones. We’re probably not going to see a change in VCs’ behavior, though. The truth about that industry is that it’s celebrity-driven, and the VCs have a lot to gain and lose by playing the reputation gain. No one cares about the difference between a 7% and an 12% annual return on investment, but there’s a lot of credibility that comes from having “been in on” a Facebook or a Google. This also explains the (justly) hated tendency of venture capitalists toward collusion, co-funding, and reliance on social proof. One might want for VCs to compete with each other (i.e. do their jobs) and avoid this sort of mediocritizing collusion, but with the career benefit of being in on the once-per-decade whale deals being what it is, the incentive to spread information (even at the expense of entrepreneurs, and of ethical decency) around is obvious.

A successful business could easily be built by focusing on the mid-growth / mid-risk space, and delivering an option that removes personal financial risk while avoiding the ugliness and the aggressive risk-seeking (even at the expense of the ecosystem’s health) of traditional venture capital. That would also reduce reliance, for businesses, on the geographical advantage of Silicon Valley, which is access to ongoing capital and the perception of a liquid market for talent. It could be very profitable. It could be this mentality that builds the next ten thousand great companies. It won’t be done in Silicon Valley, however; and when it happens, it won’t come from anyone attempting to, or even cognizant of such a concept, create “the next Silicon Valley”. It will be driven by people creating the first something.