By Kyle Campbell, a law student at the University of Alabama

Nearly everyone who has taken a philosophy class is familiar with the “trolley problem.” In the problem, a train is hurling towards a fork in the track and will soon hit and kill five people who are trapped in its path. The reader has the option to pull a lever, which will divert the train to another track on which one person is trapped; the moral dilemma is whether to actively choose to end one person’s life to save five other people whose lives the reader was not responsible for saving. I personally would pull the lever, but there are many people who wouldn’t and many legitimate moral arguments for not doing so.

Elected officials face a slight variation on the trolley problem all the time. Here, a train is hurling towards a fork in the track and will soon hit and kill five people, but rather than another person on the other side of the track, there sits someone’s property – in the form of money or anything else – that will be lost to save those five lives. No defensible moral code would allow anyone not to pull the lever, and yet refusing to pull the lever is the governing philosophy of nearly half of this country, manifested most clearly in the Republican Party but also shamefully adopted by many Democrats.

As grotesque as the valuation of property over human lives is, it is so common that most people necessarily avoid thinking about it. If we acknowledged the blood required to maintain our ways of life, our society would come apart. We are so accustomed to this selfish and immoral ideology that we reduce advocacy for life-ruining and life-ending policies to mere differences of opinion. Yet there is one policy so severe – so needlessly cruel and heartless – that it shocks the consciences even of the desensitized. As has so often been the case for similar policies over this country’s history, you can find that policy in Alabama.

Alabama’s refusal to expand Medicaid, true to our state’s moral framework, is generally written about in economic terms. Many have called attention to the fact that the federal government footed the full bill for the expansion for three years, and that it now offers more than a ten-to-one return on dollars states invest into their Medicaid programs. Economists and health policy experts react incredulously to lawmakers’ refusals to accept Medicaid expansion in the face of these numbers, but their arguments miss the mark. Not even the “Deal of the Century” will be persuasive to people whose actions show that they fundamentally do not care whether residents of their state live or die. Alabama’s officials have had every opportunity to pull the lever and send the train to an empty track, and they have chosen to do nothing every time.

The data on refusal to expand Medicaid are clear. In one study, researchers found that for every mile increase in distance to the nearest hospital, deaths due to unintentional injury and heart attack increase by six percent. For residents of Alabama communities where thirteen hospitals (including seven rural hospitals – one this week in Georgiana) have closed since 2011, distance to the closest hospital has increased by far more than a mile. Another study in the Journal of Health Affairs found that: “[T]he ACA’s Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion.”

For three years, Alabama had the opportunity to receive money to keep these hospitals open at absolutely no cost to the state. In the years since, the federal government’s share of the burden has fallen all the way to 94 percent, and next year it will fall to its lowest portion of 90 percent. Even if the state had to pay the full dollar to keep these hospitals open, to save the lives of vulnerable people in isolated communities, it should have done so. But it wouldn’t even chip in a dime. Governors Bentley and Ivey have presided over executions of people responsible for far fewer deaths and far less suffering than each of them is for this decision alone.

Often, when I try to understand how people could possibly live with themselves after making such decisions, I look back at photos of lynchings. In some pictures, while dozens or even hundreds of men, women and children surround a suspended corpse that was screaming in agony just moments before, they look at the camera and smile. Some of their smiles seem malicious, but those are a minority. Most of them just seem content, as if posing for any other photo, drowning future viewers with their callous indifference. It is this indifference that enrages me, nearly as much as the lynchings themselves. I would love to think that when a hospital closes, the people responsible aren’t able to sleep at night – that they’re haunted by the ghosts of those who, but for their indifference, would still walk the earth. I would love to think that. But deep down, I know they’re all just smiling.