How a rage-filled meeting about healthcare reform launched a journey through Madison, the opioid epidemic, COVID-19, and into the intelligence age
A Moment of Reckoning
Before the town hall, there was Yom Kippur.
Eleven years ago, I sat in my backyard instead of attending synagogue, listening to a recording of the ancient prayers. The Unetanneh Tokef — who will die by fire, who by water, who will be impoverished and who enriched — pierced me, particularly in Leonard Cohen’s haunting rendering. Something broke open.
As a practicing psychiatrist for more than thirty years, I had accumulated an insider’s view of both the American healthcare system and the inner lives of my fellow citizens. Sitting in that backyard, it struck me with sudden clarity: many of the people fated by that prayer would meet their end not through war or plague in any ancient sense, but through preventable medical errors, lack of access to care, inability to afford treatment, or simply the conditions of poverty that predispose people to illness. Medical bills would bankrupt many more. That afternoon, I set myself a mission: to help create the best healthcare system for all Americans — one defined by access, quality, safety, and affordability.
But a mission without a means is only a wish. It became clear almost immediately that meaningful change would require political engagement. The question was how.
The Room That Changed Everything
It was 2009. I had seen a flyer at a local deli advertising a town hall meeting at the National Constitution Center in Philadelphia. Secretary of Health and Human Services Kathleen Sebelius and Senator Arlen Specter were scheduled to discuss what would eventually become the Affordable Care Act. I went expecting a policy conversation — questions about coverage and costs, the careful qualified language of policy professionals meeting a curious public.
What I got was something else entirely.
The room was full of my neighbors — people I recognized, people who lived near me, people who worked in the same communities I did. And they were enraged. Not skeptical, not concerned, not even opposed in the measured way that characterizes ordinary political disagreement. Enraged. “They’re taking our rights and giving them to others,” people said, over and over, drowning out any attempt at substantive exchange.
I did not agree with their reasoning. I did not share most of their conclusions. But I could not dismiss what I was witnessing, because I was not watching it as a citizen watching other citizens. I was watching it as a psychiatrist. And what I saw, sitting in that room, was a community in genuine distress — frightened people whose fear had curdled into fury, whose sense of powerlessness had found the only outlet available to it: noise.
I had gone believing healthcare reform could be won through the political process as it then existed. I came away with a more complicated education. The passion I witnessed that afternoon has never left the American body politic. It has only intensified, spreading from healthcare to encompass nearly every dimension of civic life.
I drove home shaken, and I have been trying to understand what I saw there ever since.
The Doctor’s Habit of Mind
Let me say something about professional formation before I go further, because it shapes everything that follows.
A psychiatrist’s training instills a particular habit of mind that is both a discipline and, I have come to believe, a civic gift. You learn to hold the presenting symptom and the underlying cause simultaneously — to understand that what a patient displays in the consulting room is almost never the whole story, and that treating only what is visible rarely produces lasting change. You learn that behavior which looks irrational from the outside is almost always rational from the inside, given the patient’s history, fears, and available options. You learn that diagnosis precedes treatment, and that a wrong diagnosis — however confidently delivered — leads to interventions that make things worse.
And you learn, above all, that the organism has resources. That resilience exists. That the question is not only what has gone wrong but what conditions would allow what is right to flourish. This is the salutogenic turn — the shift from asking what causes disease to asking what creates health — and it is as applicable to the body politic as it is to the individual patient.
When I walked out of that town hall meeting in 2009, I was applying this framework almost without realizing it. I was not asking: how can these people be corrected? I was asking: what conditions produced this level of distress? What is the underlying disease? And what would a treatment plan actually look like?
Watching Obamacare: Hope, Compromise, and Political Reality
When Barack Obama was elected in 2008, I felt the kind of hope that can make a person naive. His focus on healthcare as a central priority seemed to vindicate everything I had been working toward. I attended house meetings, joined the broader citizen conversation, and followed the legislative process with the intensity of a patient waiting for a diagnosis.
Political reality intervened quickly. Tom Daschle, nominated to lead the reform effort, withdrew after a tax controversy. The special interests that candidate Obama had criticized were soon seated at the table, helping write the very legislation meant to constrain them. I became — for a time — a passive observer, virtually addicted to C-SPAN, absorbing committee hearings and call-in programs and commentary from across the ideological spectrum.
When the Patient Protection and Affordable Care Act was signed into law on March 23, 2010, I was cautiously optimistic. The law expanded coverage and contained important provisions around transparency and quality — real gains. But it was far from the systemic reform I had envisioned, and its implementation exposed both the limits of the legislation and the dysfunction of the political system that had produced it. With each legal challenge, each federal election, each battle over implementation, the nation grew more polarized. Digital technology was simultaneously rewiring the body politic, with social media platforms increasingly shaping — and inflaming — how Americans understood themselves and one another.
Hannah Arendt, writing in 1970, had anticipated precisely this corrosion: “Representative government is in crisis today, partly because it has lost, in the course of time, all institutions that permitted the citizens’ actual participation, and partly because it is now gravely affected by the disease from which the party system suffers: bureaucratization and the two parties’ tendency to represent nobody except the party machines.” The crisis she named half a century ago had only deepened.
Madison as Mentor
The diagnosis led me, somewhat unexpectedly, to James Madison.
I say unexpectedly because Madison is not the obvious entry point for a psychiatrist interested in civic health. But the more I read, the more I recognized a familiar methodology. Madison, preparing for the Constitutional Convention in the spring of 1787, did not simply show up with opinions. He spent an entire winter analyzing the histories of past republics — Greek, Roman, Italian, modern European — diagnosing their defects with the systematic rigor of a clinician working through differential diagnoses. His “Vices of the Political System” was both his findings and his prescription: a document that identified the pathology of the Articles of Confederation and proposed the structural interventions that would address it.
He was doing, in other words, exactly what I had been trained to do. He was taking a presenting symptom — the dysfunction of the early American republic — and working backward to its causes, then forward to its treatment.
What struck me most, though, was his analysis of human nature. Madison was not naive about what people are. He understood, with unusual clarity, that human beings are tribal, passionate, prone to faction, and capable of extraordinary destructiveness when those tendencies are amplified and organized. His famous line from Federalist No. 10 hit me with the force of clinical recognition:
“So strong is this propensity of mankind to fall into mutual animosities, that where no substantial occasion presents itself, the most frivolous and fanciful distinctions have been sufficient to kindle their unfriendly passions and excite their most violent conflicts.”
This is not a historical observation. It is a description of the neuroscience of in-group/out-group dynamics, written 230 years before the relevant neuroscience existed. Madison had arrived at it through observation and historical study. We have since confirmed it in the laboratory. The mechanism is the same: the human brain, shaped by millions of years of survival in small competitive groups, is primed to identify threats, activate tribal loyalty, and escalate conflict — and these tendencies are not weaknesses to be shamed but adaptive features to be understood and, in a democracy, actively designed around.
Madison’s solution was architectural: build a republic large enough and complex enough that no single faction could capture the whole. Create enough friction in the legislative process that passion might cool before it became policy. Distribute power across branches and levels of government so that no single actor could accumulate enough authority to override the system’s self-correcting mechanisms.
It was brilliant structural engineering. What it could not engineer for — what Madison could not have anticipated — was a 21st-century information environment specifically designed to accelerate the very passions his architecture was meant to slow.
For the past twelve years I have studied Madison’s political philosophy, his analytic methods, and the personal qualities he brought to bear on the political dysfunction of his era. Had he lived today, with access to modern neuroscience, behavioral psychology, and network theory, what might he have built?
The Disease Deepens
Between that 2009 town hall and the writing of this essay, I watched the diagnosis I was forming become more urgent with each passing year.
The opioid epidemic gave me my first serious case study. Here was a challenge that cut across every demographic, every geography, every political affiliation — a genuine public health catastrophe that exposed, with terrible clarity, the multiple simultaneous failures of systems designed to protect citizens: the regulatory failure that allowed pharmaceutical companies to market dangerously addictive substances with impunity; the medical community’s failure to accept the responsibility that comes with prescribing power; the law enforcement approach that criminalized suffering rather than treating it; the media’s tendency to sensationalize victims rather than illuminate causes; and above all, the political system’s inability to mount a coordinated, evidence-based, citizen-centered response.
What the opioid epidemic revealed was not the failure of any single institution. It revealed a systemic failure of the information and deliberation infrastructure that should allow citizens to understand what is happening, hold relevant actors accountable, and organize meaningful collective response. People were dying by tens of thousands annually, and the public conversation was a chaos of blame, denial, political posturing, and competing narratives — none of which was organized around the question that should have been central: what does the evidence tell us, and what can citizens do about it?
The election of Donald Trump in 2016 sharpened the clinical urgency further. Tens of millions of Americans had correctly diagnosed that the body politic was seriously ill. But the proposed cure — Trumpism as radical treatment — carried risks that, like many aggressive cancer therapies, threatened to be as destructive as the disease. As a physician, I recognized the pattern: when patients are desperate, they reach for dramatic interventions. The role of the responsible clinician is not to dismiss the desperation but to offer a more measured and sustainable treatment plan.
The COVID-19 pandemic then amplified this diagnosis to an almost unbearable degree. Here was a global crisis in which the quality of information — its accuracy, its accessibility, its organization, its relationship to actionable public guidance — was literally a matter of life and death. And the information environment we had built, optimized for engagement and emotional capture rather than comprehension and informed action, failed catastrophically. Not because the science was absent. Because the medium through which the science should have reached citizens had been corrupted, fragmented, and weaponized by incentives that had nothing to do with public health.
Both crises confirmed what the 2009 town hall had first shown me: the presenting symptom is rage and disengagement. The underlying disease is the systematic destruction of the conditions under which citizens can form considered public judgment.
Aaron Swartz and the Path Forward
The final element that brought my thinking into focus came through an unexpected encounter with tragedy.
Reading about Aaron Swartz — the internet activist who took his own life while facing federal prosecution for downloading academic articles from an MIT server — I found myself overwhelmed in a way I had not anticipated. His story stirred a grief that reminded me of my mother, who at eighteen had been jailed in Poland for years, convicted of carrying political literature. The echo across time and across continents was not lost on me: the state, threatened by the free circulation of ideas, reaching for its most punishing tools.
But beyond the grief was illumination. Swartz had understood something essential about the relationship between technology and democratic change:
“Change doesn’t come from thousands of people, all going their separate ways. Change requires bringing people together to work on a common goal... They can measure their success by the number of lives that have been improved by the changes they fought for, rather than the number of people who have visited their website.”
This reorientation — from individual action to collective purpose, from traffic to impact — gave me the organizing principle I had been searching for. Technology, Swartz insisted, was not neutral. Deployed in service of transparency and collaboration, it could strengthen democracy. Deployed in service of engagement metrics and outrage, it would corrode it. The choice was not technical. It was political. It was ethical. It was, ultimately, constitutional.
What Madison Would Recognize
I have spent years asking what Madison would make of our current moment, and I think the answer is more complicated than either his admirers or his critics usually suggest.
He would recognize the factions immediately. He would understand the mechanisms by which passion overwhelms reason when it moves faster than deliberation can follow. He would recognize the capture of legislative processes by organized financial interests — it was already happening in his lifetime, and he saw it clearly.
What would genuinely surprise him, I think, is the scale and precision of the tools now available for manufacturing and sustaining faction. He knew that communication infrastructure shaped the quality of public opinion — it is why he argued so insistently for a free press as constitutional infrastructure, and why he helped found the National Gazette as a platform for reaching citizens directly. But he could not have imagined a communication environment in which the entire incentive structure of media is organized around activating the precise psychological vulnerabilities he identified in Federalist No. 10 — and doing so continuously, at scale, to hundreds of millions of people simultaneously.
He would also, I believe, recognize the remedy. Not the specific technology — that is beyond anything he could have imagined — but the principle. Whatever facilitates “a general intercourse of sentiments,” he wrote, is favorable to liberty. Whatever helps citizens understand their shared environment, form considered views, and act together as the sovereigns of their government — that is the infrastructure democracy requires. The printing press was the technology of his time. The question of our time is whether artificial intelligence can be governed to serve the same purpose.
That is the question Moonshot Press exists to answer.
The Arc From Shrink the Government to Moonshot Press
For those who knew the earlier work under the name “Shrink the Government” — a website that is no longer active — a brief accounting of the journey is in order.
The Citizenism Project, which that site hosted, was the first systematic attempt to develop what I was calling a citizen’s user manual for democracy. It proposed the Medical Case Presentation as a framework for civic deliberation — the same clinical structure I had been using for three decades to address complex, multi-factorial problems with life-and-death stakes, now applied to the pathology of the body politic. It introduced the Citizen Brief as a tool for organizing complex public challenges into accessible, actionable form. It developed the ecosystem lens — borrowed from complexity science — as a way for citizens to understand the stakeholder landscape of any given political challenge. And it argued, presciently I think, that digital technology could either enrich democracy or infect it, depending entirely on whether it was governed by civic values or commercial ones.
The opioid epidemic was the first live experiment. The COVID-19 pandemic was the second, unwanted, and vastly larger one.
What both experiments confirmed was that the framework was sound but the platform was insufficient. A website, however well-designed, is not a press in Madison’s sense. It does not have the institutional architecture, the editorial standards, the constitutional governance, or the human judgment structures that the third job of the press — deliberation, the formation of considered public judgment — actually requires.
Moonshot Press is the attempt to build that. Its constitution — a public document that governs not only what the journalism may do but what the artificial intelligence may do — is the direct descendant of everything the Citizenism Project was reaching for. The Citizen Briefs, the People’s Commission, the deliberative tools, the commitment to citizens as authors rather than audiences: these are the Citizenism toolkit, matured and institutionally grounded.
And the question that launched all of it — what I saw in that room in 2009, and could not stop thinking about — remains the animating one: what conditions allow citizens to function as the sovereigns Madison was counting on, rather than the frightened, enraged, helpless audience they had become?
The Prognosis
Benjamin Franklin’s warning at the close of the Constitutional Convention is the one I return to most often. The republic will work, he said, “for a Course of Years” — and will end in despotism “when the People shall become so corrupted as to need Despotic Government, being incapable of any other.”
Franklin was not predicting moral failure. He was predicting institutional failure — the failure of the conditions under which citizens can exercise the judgment that self-government requires. Corruption, in his usage, means not venality but incapacity: the incapacity that results when the information environment is poisoned, when the tools for meaningful participation are unavailable, when the distance between the citizen and the decisions that affect their life becomes so vast that engagement feels not just difficult but absurd.
That incapacity is treatable. It has been treated before. The abolitionist press, the labor movement, the suffragists, the civil rights organizations — each built information infrastructure that gave their constituencies the tools to function as active, informed, reasoning citizens. Each, in its own way, was doing what Madison did in 1787: diagnosing the pathology, developing the treatment plan, and trusting that citizens, given the right conditions, were capable of the thing democracy requires of them.
The vision I set for myself in that backyard on Yom Kippur — excellent, safe, quality, affordable healthcare for all Americans — has not changed. What has changed is my understanding of what achieving it requires. It requires citizens who understand the system they inhabit well enough to diagnose its pathology, deliberate about its treatment, and act with the sustained commitment that genuine healing demands.
We are doing it again. With tools Madison could not have imagined, toward a purpose he articulated with complete clarity: the care of human life and happiness, and not their destruction, as the first and only legitimate object of good government.
James Madison built the architecture. Aaron Swartz pointed toward the tools. The work of citizenship remains ours to do.
The patient is sick. The diagnosis is serious. The treatment exists.
The question, as it has always been in medicine and in democracy, is whether we will administer it in time.
The author is a psychiatrist and the founder of Moonshot Press. The Citizenism Project, developed over the past fifteen years, is the intellectual foundation of Moonshot Press’s citizen-centered approach to civic journalism and deliberation. Shrink Notes is a Moonshot Press column applying clinical and psychological frameworks to the challenges of democratic life. Earlier versions of this work appeared on Shrink the Government, a predecessor site no longer active.
Civic Call: The tools described in this essay — Citizen Briefs, ecosystem analysis, the People’s Commission framework — are active at Moonshot Press. The People’s Commission on Technology and the American Future is the current live experiment in citizen-centered deliberation. [Join the Commission →]