I mean, hell, you can't walk through the opioid epidemic in America without running into our massive and almost entirely carceral response to it. There's a whole generation out there of children who barely know their parents, because we decided their parents' sickness is a crime, and one for which the only solution is lockup, not treatment (a standard, of course, never set for people who have money).

Howdy y’all,I just got back from the road -- spent some time in south Texas, Houston, Wisconsin, and Illinois (a real pain in the ass to pack for). I’ll be in Idaho next week with the Reclaim Idaho folks stumping for their Medicaid Expansion campaign. I think it’s one of the most exciting things happening in the US right now (which, admittedly, sometimes feels like admiring some tinsel smushed within a pile of dogshit) and I’m very excited to return to the state. If you live around there (especially the northern part), please come drink a beer with me and tell me about health inequity in your county.Enough of that for now.Two days ago I was on a train between Milwaukee and Chicago. In Chicago you speak to anyone about healthcare and it’s not long before someone mentions that Cook County Jail is the largest provider of mental health services in Illinois (in all of the US, I believe). And, hell, it’s the same case in virtually any state I visit. In Austin, TX, Travis County Jail is the largest mental health provider; in Houston, it’s Harris County Jail; same for several large counties in Georgia; in New York, it’s Rikers.And that’s a good and necessary truism but it doesn’t explain adequately the mechanism by which the delegation of mental health services to the carceral state happens, or what it looks like. So let’s talk about that.I got the chance to speak with Franklin Bynum , a former public defender who’s running for judge in Houston (because “running for judge” is a thing you still do in Texas). As a rule I am skeptical of elected officials and the people who wish to become them, but I like Franklin quite a bit. He walked me through the judicial process by which the link between mental health and prison is forged. (Disclaimer: this summary is from my own notes and memory and should not be considered a campaign statement by Bynum or whatever. Any inaccuracies are mine.)Every day, he said, received a few names of people with mental health disorders who were being held in the Harris County Courthouse, a sleek and pretty modern building in downtown Houston, just a few blocks from a bail bond lender and a former slave market. Detainees are held behind each courtroom in dark, dank, dungeonesque cells, hidden from public view. Franklin visits a detainee and introduces himself.If the detainee is capable of introducing themself and identifying Franklin, it was, ultimately, Franklin’s job to help them plead guilty. Not because they were necessarily guilty -- but because judges refuse to release people on personal bond, and set cash bond far, far out of the reach of the common defendant. This coerces defendants to plead guilty so they can go home -- and thus “speeds the docket” for the courthouse so the judge has less work to do. For a person who needs medication to survive, the coercion is overwhelming.And, frankly, this is all if they’re lucky enough to be able to pass as functioning normally. If the detainee is unable to identify themself; if they’re in the middle of a serious mental health episode, things become more drastic. The detainee can now be held for up to thirty days until the county can provide them with a psychologist. So they’re held in a hospital wing of the prison, or a prison wing of the hospital.There's this concept of the “prison-to-hospital” pipeline. It's more like a pinball machine. Giant, invisible flippers bounce people around, from jail to hospital to jail to hospital, and at some point, there's no functional difference between the two. We refuse to care for people, and so they become sick. We make them sick. And if you’re the wrong kind of sick, or if you’re the wrong kind of person, we delegate your care to the prisons. This is the mechanism which keeps me paying thousands of dollars a month for basic healthcare I need to stay alive--unlike my uncle, who was born at the wrong time and in the wrong place, with the same mental disorder but fewer effective drugs, and who was bandied between jail and hospital for decades as punishment.The same snakes arise. It's technically not a crime to be poor; it's technically not a crime to be sick; it's technically not a crime to be black or brown; but once you fall into the intersections the rules change on you. If you're a poor single mother, if you're a poor mother of color, for example, you have virtually no right to privacy . If you're in Section 8 housing, a state agent comes to your apartment twice a month and counts the shoes on your shoe rack. If they find too many you lose your benefits. If you're disabled and on Medicaid, every month a nurse comes to your house to check if you're still disabled, or if you're faking it. If you’re a Medicaid recipient in a work requirements state, every month you gotta wait in line for hours at an intentionally understaffed office to prove that you’re employed.The Democrats, the liberals; they know this is bad. And “luckily,” they have a plan. A few years ago I volunteered on a project for the benevolent-billionaire Arnold Foundation , also based in Houston. They wanted to understand what predicts recidivism — that is, why do people who go to jail go back to jail? So they took these three brilliant data scientists, plus me, and we got our little Mission Impossible cleanroom style virtual machine, and we looked at police records, and jail data, and courthouse records. And after all this hemming and hawing, after all this brainpower and technical expertise, we discovered that the people who go to jail most often are people who are arrested for being homeless. They get arrested for being homeless, they go to jail for being homeless, then they get released and remain homeless.This is a revelation for these people.Now the Arnold Foundation takes projects like these and builds little black boxes for judges to help them figure out who to sentence and for how long, based on characteristics of people who have previously been sentenced to prison. And, as literally anyone could predict, this means that poor people, people of color, and sick people just keep getting sentenced in exactly the same way as they were before. Except this time, a computer tells the judge they’re doing the right thing.This is the neoliberal approach to the carceral state. Not to dismantle it, but to rationalize it. To invent processes which reenact already-existing acts of structural violence—the dehumanization of poor, sick, and black or brown people—then cite those old acts of violence as justification for the new acts of violence. It is a tautological model of immiseration.And so I want to be explicit.. Our goal is not healthcare but emancipation. We must put the people who have been most harmed at the front of the line. We must walk together every goddamn step of the way. A movement that is satisfied by a bill that already exists, or which organizes around a bill, instead of around and among the people who are most immiserated, will follow its historical predecessors and fail --and has already failed. We must never compromise until we all have been liberated.