Illustration by Jim Cooke/GMG.

There are, according to Representative Mo Brooks (R-AL), people who have lived “good lives”; Americans who have “done things the right way,” and have kept “their bodies healthy.” Those citizens, Brooks said in a CNN interview, deserve a reward for their good health; they deserve to have their health care costs reduced, they deserve to have Obamacare repealed and replaced.

Brooks’s comments, made nearly two months ago, typify the Republican response to criticisms of both the House and Senate versions of their health care bill. An image of health has accumulated in the Republican push to repeal Obamacare, one that is steeped in a particular fiction of morality. It’s an image of good Americans who have kept illness at bay, not because of good fortune or geography or genetics or any of those fickle things that determine one’s health, but because they have lived their lives well. That image, that picture of health, exists in contrast to an image of illness. In these two separate fictions, the reality of illness—particularly the materiality of pain—has been rendered virtually invisible, replaced instead with metaphors that treat the expression of individual pain as suspect. Illness remains inexpressible even as the health of the state becomes central to the composition.

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Though Senate Majority Leader Mitch McConnell (R-KY) announced on Tuesday that he would delay the vote on Republican health care bill until after the July 4 recess, like its House version the bill is sure to have a second life, as is broader health care debate.

Republican lawmakers rely upon a stereotype of the sick or the disabled as irresponsible, citizens who have laid waste to their health through irresponsible decisions. Vice President Mike Pence implied such waste when he called for replacing Obamacare with a “system based on personal responsibility.” The “free market and state-based reform” Pence said, would correct the irresponsibility plaguing the market; ostensibly illness itself.

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Or, perhaps, Kellyanne Conway expressed that concept more clearly when, during an interview with ABC’s This Week, said that the expansion of Medicaid under the Affordable Care Act was too friendly “to able-bodied Americans.” “If they are able-bodied and they want to work, then they’ll have employer-sponsored benefits like you and I do,” Conway said when asked about the estimated thousands who will lose their Medicaid coverage.

In his comments, Brooks eventually added that there are some who have “pre-existing conditions through no fault of their own.” But the authentically sick are the rare minority, such comments imply. Instead, good and healthy Americans, those who have practiced moderation in all things, are being taken advantage of by those who feign illness, emboldened as they are by legislation that shuns the free market (itself emblematic of inherent good), thus rewarding laziness. Pain might but real—indeed, some people might be in pain—but its expression remains suspect.

Coding illness as a character flaw isn’t particularly original, nor is it specific to Republicans in this political moment. The forced invisibility of the ill, the pretense that the articulation of pain isn’t somehow political, likely pre-dates the invention of modern medicine. What Susan Sontag once called the two “kingdoms” of the “well” and the “sick,” are ancient, constructed with metaphorical border walls whose foundations are formed deep in our political core. These two kingdoms are increasingly central to the American idea of health care, hinting at what Republicans have recently made explicit: simply, that most citizens of the kingdom of the sick deserve to be there.

Though, as Sontag writes, every person “holds dual citizenship” in both kingdoms, the treatment of illness along moral lines allows us to believe that the kingdom of the well can be isolated, that it’s morally superior citizens will experience illness as a singular moment of tragedy, not a lifetime occurrence. There is no poverty in this rendering, it is a picture free of anyone who stumbles financially on the often long path to death; no one who is unable to face the staggering costs of a child who will require a lifetime of care; no one who is unprepared to meet the challenges of the free market. There is “nobody,” according to Representative Raul Labrador (R-ID), who “dies because they don’t have access to health care.”

The kingdom of the well is a utopia of sorts—no poverty, no pain, no accumulation of costs from chronic health problems. But it is, apparently, deeply unstable place, constantly teetering on the brink of disaster. “Every moment Obamacare survives is another day America suffers,” Pence said. Pence’s words are telling, couched as they are in a series of medical metaphors, also suspended between survival and suffering. Here, pain is located both abstractly and geographically, within the principles of the state rather than in flesh and blood people; America “suffers,” while the pain of Americans is unspoken.

The disease metaphor is inherent to politics and its usage precedes political persuasion. The diseased body of the state, one that requires a heroic and perhaps violent act of intervention in order to be saved or resuscitated is a near constant of modernity. In Illness as a Metaphor, Sontag cites examples of such imagery employed everyone from John Adams to French Revolutionaries, Bolsheviks to Nazis and in the Nixon White House. Pence is just another addition to a long tradition.

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“The melodrama tics of the disease metaphor in modern political discourse assume a punitive notion: of the disease not as a punishment but as a sign of evil, something to be punished,” Sontag wrote. Within the healthcare debate, the disease metaphor spreads from state to citizens, acting like a contagion. The suffering of the state is a failure of morality; whatever ails it (Obamacare) will inevitably infect the citizens who have otherwise lived good lives.

But then, fear of contagion is part and parcel of the current Republican ethos, particularly as exemplified by Donald Trump. Think of the increasingly long list of people who are contagious, of bodies that can infect the state: undocumented workers, “radical Islamic terrorists,” the poor, the haters and losers, black and Latino teens, protesters, snowflakes, hysterics, and an entire political party who are “not even people.” Perhaps that’s why while still on the campaign trail, Trump employed the disease metaphor, promising to make America great again, as Pence said, relieve the nation from its suffering. The Trump rhetoric promises to do so through quarantine, to “build that wall” or “lock her up,” to seal off the kingdom from those who bring disease and inflict suffering upon the state. Walls can be built and travel bans issued, but borders are porous and they cannot isolate the state from its own citizens. Instead, metaphors suffice, easily preserving the ideal body that visibly haunts the Trump worldview, transforming the rest into an image of disease and deceit, into something to be punished.

That a particular section of the Trump right is dedicated to the preservation of an ideal white body is indisputable. Trump himself has often conjured up virility and masculinity as evidence of potent health, painting his opposition in the broad strokes of disability or femininity: “Leakers” undermine his presidency as people of color threaten to undermine the security of the country. The boundaries of the health care debate are an extension of this kind of rhetoric, a kind of border wall in and of itself that promises to quarantine from the sick and disabled. The kingdom of the well is not only wealthy and healthy but it is also implicitly white. While this is implicit it is rarely made explicit.

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To simply mock the disabled as Trump did in August 2016 invites criticism that’s nearly impossible to combat, such animosity chafes at common decency, but to turn disability or illness into something that is morally suspect, to place it into the same category as criminality, that’s just politics as usual.

Democrats have responded to the Senate Republicans’ plan, the Better Care Reconciliation Act (BCRA) by calling it “mean.” That description, first offered by Donald Trump to describe the House version of the bill, has been echoed on social media. In a nearly 1,000 word Facebook post, former President Barack Obama wrote of the “fundamental meanness at the core of this legislation,” adding that the BCRA is “not a health care bill” but “a massive transfer of wealth from middle-class and poor families to the richest people in America.” Nancy Pelosi had offered a similar assessment immediately after Republican leadership finally released a draft of the bill last week. Pelosi described it as a “tax bill disguised as a health care bill.” Those two talking points solidified, Democrats have repeated them relentlessly.

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The BCRA is mean, I suppose, but meanness doesn’t quite capture that worldview that produced such legislation. Meanness sounds too petty, too much like a schoolyard taunt; it doesn’t quite capture the deliberate punishment of others for whom, this worldview implies, such treatment is simply a forcible return to the natural way of things. To call it cruel seems like an understatement. The infliction of pain on others while simultaneously denying the real physicality of that pain seems beyond cruelty. The irony is that Republicans contend that they are concerned with suffering, at least in the abstract.

Even as the BCRA will, according to the Congressional Budget Office, leave 22 million more uninsured, it will reduce the deficit, it will offer a financial reward to those Americans who have “done things the right way.” There is a conflation here with financial inconvenience with the pain of illness or disability, a constant suggestion that freedom exists as a financial metric, boxes ticked on IRS form, as though wealth absolves you from reconciling personal comfort with the lives of others. Politically and historically, I suppose it does—wealth and power have never much concerned themselves with anything but their own preservation, regardless of the repercussions for others.

That seems particularly true within the health care debate where rising costs and high drug prices exist within the narrative of “policy”—a word that conjures up with unconvincing intellectual pretense wonks like Paul Ryan while simultaneously taking for granted the pervasiveness of the disease metaphor. It’s a pretense that allows healthcare to live in the tick-tock of the news cycle, to remain embedded within the expectation of respectful political speech, all the while rendering the reality of illness invisible. Take, for example, Senator Orrin Hatch’s response to Bernie Sanders. “Let us be clear and this is not trying to be overly dramatic,” Sanders tweeted. “Thousands of people will die if the Republican health care bill becomes law.”

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“The brief time when we were *not* accusing those we disagree with was nice while it lasted,” Hatch responded.

Image via Twitter.

Here, death becomes unspeakable, pain invisible, and respect necessary. The glib exchange is a potent reminder that the expression of pain, as Elaine Scarry wrote, “is bound up with the problem of power.”

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The disease metaphor is pervasive, it creates dueling images of both the sick and the healthy, treating both as natural, writing them into a perception of the health of a nation. The image replaces reality, replacing real people—real disease and disability—with abstraction. Even as it has become a standard expectation for Americans to publicly share their health stories, to repeat harrowing details of sick children, to bring those children to Capitol Hill, to stage die-ins, and to narrate pain and trauma and stress, those personal stories are consumed, turned into something suspicious and criminal.

To speak of death, or to speak of pain is to be suspect, to use “inflammatory language” or be labeled dramatic. And yet the consequences for speaking of neither are even higher. Instead, death and life are forced to exist in most abstract terms—as a political philosophy or policy or simple disagreement rather than toward the articulation of pain. “That’s the Republican way. That’s the American way,” Pence said.