Book summary “So much for that”: summary

Introduction

You spend years building a deliberate financial escape plan to buy your freedom from the grind. Then a sudden catastrophic illness strikes, turning your long-term dreams into collateral damage against towering hospital bills.

Catastrophic illness and soaring healthcare costs test long-held escape fantasies, exposing the grim financial and emotional realities of the American medical system.

Lionel Shriver examines how systemic failures in modern medicine collide with personal responsibility, marital loyalty, and societal divisions. The book tracks the psychological toll of caregiving and the brutal arithmetic of American health insurance through five distinct movements.

• How do you balance a lifelong dream of reinvention with the immediate demands of a dying partner?
• What happens to your relationships when financial ruin replaces personal autonomy?
• Who actually pays for the bloated inefficiencies of modern healthcare?

1. The Afterlife and Financial Foundations

Shep maintains a personal financial portfolio to fund his long-term exit strategy to Pemba, while navigating marriage dynamics and early entrepreneurial self-reliance.

You can build long-term plans on the absolute independence of a private account. Shep keeps his Merrill Lynch account strictly in his own name to fund his relocation to developing nations. At the end of December 2004, this Merrill Lynch Account Number 934-23F917 shows a net portfolio value of $731,778.56.

The Wedding Fountain was the only project Shep and Glynis built together. It represented a synthesis of her technical metalwork and his practical water mechanisms, which eventually became an allegory for their failed ideals. Twenty-six years prior to these events, Shep and Glynis crafted a sterling silver fountain for their wedding gathering, combining her soldered metal sluices with his concealed water pump mechanics.

When Shep was sixteen years old, his father Gabriel took the family to Limuru, Kenya. There, Shep discovered that an entire week's worth of fresh market groceries cost less than three dollars in 1972 currency. This early exposure to drastically different purchasing power scales shifted his perception of money.

Building Capital and Escaping Corporate Servitude

You can start an enterprise without traditional academic credentials through sheer physical toil and thrift. Shep delayed college to start Knack of All Trades out of a cheap one-bedroom apartment in Park Slope, Brooklyn, after earning five dollars from shoveling snow at age nine. He eventually incorporated the business and hired full-time help, including his friend Jackson Burdina.

In November 1996, Shep sold Knack for a million dollars to an employee who inherited a trust fund. The buyer renamed the company Handy Randy and relegated Shep to customer relations, locking him into over eight years of subsequent submission. Selling a successful business to an incompetent buyer can trap you in corporate servitude.

Financial security can inadvertently destroy an artist's drive by removing the essential resistance of necessity. Glynis, a talented silversmith and metalsmith, struggled to finish and sell her intricate artwork once Shep's income provided a comfortable cushion. Instead of producing museum-quality flatware, she carves wax bunny rabbits for an upmarket chocolatier named Living in Sin located in Mount Kisco.

You might find that modern economic mobility relies less on earned labor and wages and more on property appreciation and investment luck. Jackson and Carol's ramshackle house in Windsor Terrace soared in value to $550,000, illustrating how urban real estate booms reward property owners without requiring productive labor.

An escape fantasy becomes a definitive reality only when you cut off infinite delays. Shep purchases three nonrefundable e-tickets for BA-179 out of JFK to London, continuing on to Nairobi, Zanzibar, and Pemba, giving his family an ultimatum to leave at forty-eight years old.

2. Medical Crises and Insurance Realities

Severe chronic illness and cancer diagnoses shatter long-term escape plans, forcing individuals to endure toxic workplaces and flawed insurance bureaucracies.

You might find that a sudden health crisis instantly dissolves long-term fantasies of escape and redefines your sense of duty. Shep abandons his planned escape to Pemba after his wife Glynis is diagnosed with cancer. Rather than viewing this as a trap, he experiences it as a simplifying clarity that grounds him in his responsibilities.

Shep spends the weekend on the internet researching the diagnosis and prepares to meet with an oncologist with Glynis, completely dropping his plans to move to Pemba.

Navigating the For-Profit Healthcare Maze

Employees will endure severe humiliation and toxic corporate environments primarily to secure essential health insurance coverage. Shep returns to work and publicly humbles himself before his abrasive boss Pogatchnik, offering a total apology for an insult, solely to maintain his employment and health benefits.

Shep apologizes humbly to Pogatchnik at Handy Randy after previously telling him off, accepting the subordinate role to keep his job. Pogatchnik arrives at the office at 11:00 a.m. and keeps the office heated to eighty-five degrees.

Standard health insurance policies impose heavy co-pays, strict deductibles, and low lifetime caps that fail to cover specialized chronic care. Families like Jackson and Carol's must abandon preferred jobs for corporate employment with better plans. Carol left her landscaping career for a job at IBM because Randy switched to a cheaper health plan at Knack that could not cover Flicka's extensive medical expenses.

The World Wellness Group plan requires a five thousand dollars deductible before reimbursement begins under the plan. The co-insurance rate for in-network bills is twenty percent, and the lifetime payment cap on the inadequate health plan ranges between two or three million dollars. Insurers use a reasonable and customary doctor visit fee corresponding to the year 1959.

Peritoneal mesothelioma is a rare and serious cancer that typically remains undetected until it is quite advanced, masking itself behind vague symptoms. Dr. Edward Knox explains that the peritoneum functions like plastic wrap, allowing diseased tissue to hide in inaccessible corners. Symptoms such as abdominal swelling, tenderness, and gastric dysmotility are easily mistaken for other conditions.

Glynis hid her initial diagnostics including X rays, a CAT scan, and an MRI, and masked symptoms like internal bleeding and weight loss while wearing nightgowns to hide a laparoscopy scar. Phelps Memorial has seen only two cases of mesothelioma in the last twenty years.

Navigating serious medical treatment in the United States exposes patients to an opaque, for-profit insurance maze designed to obscure actual costs and shift heavy financial burdens onto families. Insurers use arbitrary reasonable and customary fee benchmarks generated by affiliated units, burying patients in a blizzard of contradictory paperwork and administrative delays while forcing high co-insurance payments for out-of-network experts.

Shep has to spend hours on automated phone menus listening to Greensleeves and battling World Wellness Group to get coverage for top specialists at Columbia-Presbyterian.

The net portfolio value of Shep's Merrill Lynch account from December 2004 stood at $731,778.56. Shep and Glynis would have to eat a forty percent co-insurance percentage for out-of-network care at Columbia-Presbyterian. Administration consumes thirty percent of the money spent on medical care in the US.

Mesothelioma is almost exclusively linked to asbestos exposure, a hazard known for nearly a century that can be transmitted through microscopic fibers brought home on work clothing. Because asbestos fibers have a gestation period ranging from twenty to fifty years, tracing the exact source of exposure is notoriously difficult. However, family members can contract the disease simply from hugging a worker or handling contaminated garments.

Dr. Knox shares a story of a British woman suing her Ministry of Defence because her father was an insulation engineer at a naval dockyard and she was exposed as a child. Evidence about the dangers of asbestos dates from 1918, and the specific link between asbestos and mesothelioma was established in 1964. The EPA finally banned asbestos in 1989 before the ban was overturned in court in 1991.

Long-term financial planning for retirement can be obliterated instantly by catastrophic medical expenses, turning money meant for the future into an immediate currency for buying days of life. Shep taps into his separate Merrill Lynch account, the proceeds from selling his business after paying off the federal government, which was strictly earmarked for their retirement plan called The Afterlife.

Shep writes his very first check from his Merrill Lynch account using check number 101 to pay for a diagnostic CAT scan.

Critics argue that the American healthcare model delivers inferior outcomes at double the cost compared to other developed nations due to corporate profit-seeking and administrative bloat. Jackson points out that despite the American fear of socialized medicine, nearly half the population is already covered by Medicare or Medicaid, meaning the working public pays twice through taxes and private premiums while private insurers profit.

Jackson argues that standard American healthcare metrics like infant mortality and cancer survival place the US at the bottom of rich nations despite higher spending, with fortysomething percent of the country on Medicaid or Medicare.

Caring for a terminally ill partner requires immense logistical labor and emotional endurance, transforming a spouse into an exhausted manager of appointments, paperwork, and household chores. Shep finds himself working late into the night requesting pathology slides, filling out repetitive medical history forms, cooking, shopping, and managing his job while suppressing his own panic to maintain a brave face for Glynis.

Shep stays up until two a.m. every night handling medical bureaucracy and coordinating second opinions while trying to hide his emotional turmoil.

3. Patsies and Parasites in Modern Society

Jackson categorizes society into hardworking contributors and exploiting dependents, while family conflicts and financial demands intensify during crises.

Faced with Glynis's cancer diagnosis, Shep channels all his energy into her care and preparation for her upcoming surgery. This singular mission completely replaces his previous obsession with escaping his life through The Afterlife, leaving no room for mourning Pemba or frustration with his sister.

Shep stays up until 3:00 a.m. preparing lasagna for Beryl's visit and meticulously follows recipes, using his obedience to focus entirely on Glynis's comfort.

Social Theories and Family Demands

Jackson divides society into two opposing classes: those who play by the rules and pay for everything, and those who exploit or live off the system. Jackson's worldview posits that a hardworking minority of rule-followers supports a bloated class of mooches, including government officials, contractors, lawyers, accountants, welfare recipients, and criminals who operate outside conventional taxation.

Jackson has spent years creating homespun titles for these two groups:

• Patsies and Parasites
• Mugs and Mooches
• Slaves and Skivers

According to Jackson's critique, Mugs meticulously account for minor expenses and fear tax authorities, despite watching governments waste billions. They follow laws strictly out of terror and a lack of developmental rebellion, leaving them vulnerable and exploited.

Mugs sweat over minor tax receipts down to the penny and worry about car insurance, only to be left unprotected when disaster strikes. They inspect tattered receipts with figures like $3.49 and $2.67 while governments drop $349 million through cracks in GAO floorboards and fritter away $267 billion on a dead-end war.

Shep acknowledges Jackson's cynical categories but prefers to remain a resource rather than a drain. He believes that being reliable, self-sufficient, and capable feels genuinely good, far outweighing the sneering self-congratulation of a cheat. Despite Jackson's ridicule of dependable people, Jackson has long admired Shep for embodying these very qualities.

Beryl's documentary films mirror her own life circumstances, including childlessness, debt, living in postindustrial towns, and anti-car activism stemming from her inability to afford a vehicle. Beryl made films about childless couples in their mid-forties, declining post-industrial towns like Berlin, New Hampshire, people without a sense of smell, and students saddled with college debt. She has lived in her Manhattan apartment for seventeen years.

Property owners use loopholes involving building renovations and vacancies to push buildings past a percentage threshold, removing apartments from rent stabilization and exposing long-term tenants to market-rate hikes. Beryl's landlord achieved a seventy-five percent substantial renovation threshold after taking over a neighbor's apartment, threatening to raise her rent from hundreds of dollars to thousands. A tiny studio apartment in Manhattan costs three thousand a month, while open market value for Beryl's apartment reaches five or six grand a month.

Faced with losing her rent-stabilized home and proposing to relocate their aging father into an expensive assisted-living facility funded by others, Beryl demands a massive cash down payment for an apartment purchase. Assisted-living facilities cost seventy-five to one hundred grand a year, and Beryl asks Shep for a hundred thousand dollars or so for a down payment on an apartment, viewing it as an investment while ignoring his other financial commitments.

When pushed to the limit by Beryl's financial demands and unrealistic expectations regarding their father's care, Shep halts the argument by disclosing Glynis's terminal diagnosis, shutting down any discussion of financial bailouts. Shep tells Beryl that Glynis has virulent mesothelioma, which she may have contracted from his work with asbestos, meaning his funds must be conserved to save his wife's life rather than buy his sister property.

4. Physical Crises and Absurd Modernity

Unpredictable medical crises, bizarre pharmaceutical advertising, and institutional absurdities test the psychological endurance of patients and caregivers. You find that severe illness strips away your patience for modern inconveniences and exposes the harsh reality of corporate healthcare structures.

Coping with Physical and Institutional Decay

Familial dysautonomia causes unpredictable physical crises and profound existential despair that severely tests family endurance. Flicka suffers from symptoms like corneal infections, chronic congestion, wild blood pressure fluctuations, and retching. Before a dinner party, Flicka suffers a severe retching and dysautonomic crisis requiring immediate intervention.

You must handle complex emergency medical protocols during these episodes:

• Administer a tiny marshmallow-peanut colored tablet of ProAmatine rectally for low blood pressure.
• Insert diazepam rectally to stave off a full-blown crisis.
• Keep the patient upright for three hours after administering ProAmatine to prevent dangerous blood pressure spikes.

Facing terminal cancer, Glynis shifts her focus from random misfortune to corporate fault by identifying historical exposure to asbestos products in her art school days, transforming her personal tragedy into a crusade for accountability. Glynis suddenly recalls that her soldering blocks, crucible lining, and heat-proof mitts at Saguaro Art School and from Forge Craft contained asbestos, enabling her to pursue a contingency lawsuit.

The American healthcare and employment system forces individuals to keep working during personal crises to preserve meager health insurance.

There is a strict, unwritten societal protocol that when your spouse is undergoing major surgery and you have a job providing basic health insurance, you must go to work regardless of emotional distress. Shep spends the hours of Glynis's surgery sitting at his desk handling customer complaints at work to protect his tenuous connection to health insurance.

You follow an unwritten societal rule:

• Go to work when your wife undergoes surgery if your job provides miserable health insurance and you have already missed days.

During the operation, surgeons find a biphasic patch containing sarcomatoid cells mixed with epithelioid cells, which do not respond to direct chemotherapy application and make the prognosis far less optimistic. Dr. Hartness informs Shep that the biopsy failed to detect the aggressive sarcomatoid cells, which are mixed like fudge marble ice cream, preventing the installation of chemo ports.

5. Caregiving, Finances, and Final Reckoning

Advanced cancer treatments impose astronomical financial costs that dwarf ordinary household expenses, shifting your perspective on money toward indifference. You watch your net portfolio value deplete rapidly by medical bills.

Shep receives an account statement from Merrill Lynch showing a net portfolio value of $571,264.91, which is rapidly being depleted by medical bills. Each chemotherapy session costs over forty thousand dollars a throw.

Astronomical medical costs, crumbling marital intimacy, and terminal prognoses lead to profound psychological shifts and radical choices.

The Final Calculus of Survival and Release

You cope with extreme stress by meticulously curating secret plans for an overseas escape after the ordeal concludes. For ten years, Shep has maintained hardback notebooks detailing staple prices, housing laws, weather, and logistics for potential expat havens.

Shep keeps a dedicated notebook for Pemba Island, fifty miles north of Zanzibar, noting local wildlife, seafood cuisine, and its population of 300,000.

You obtain a prescription for liquid morphine to ease final days at home without hospitalization.

• Place a few drops of liquid morphine on the patient's tongue when they seem uncomfortable.

You relocate to developing regions to drastically change your financial equation. Shep uses his remaining financial reserves and legal settlement to buy coastal land and build a home in Pemba.

10 Key Ideas

1. Shep maintains a personal financial portfolio in his own name to fund his long-term exit strategy from corporate servitude to Pemba.
2. A sudden peritoneal mesothelioma diagnosis shatters Shep and Glynis's long-term escape plans, forcing Shep to endure a toxic corporate workplace to preserve health insurance benefits.
3. Jackson divides society into hardworking rule-followers who pay for everything and exploiting dependents, while Beryl demands a massive cash down payment for an apartment purchase that ignores Shep's other financial commitments.
4. Insurers use arbitrary fee benchmarks and bureaucratic delays to shift heavy financial burdens onto families navigating the for-profit American healthcare maze.
5. Caring for a terminally ill partner requires immense logistical labor and emotional endurance, transforming a spouse into an exhausted manager of appointments and household chores.
6. Flicka's familial dysautonomia demands complex emergency medical protocols, including administering medications rectally to manage wild blood pressure fluctuations and severe retching crises.
7. Unwritten societal rules force Shep to sit at his desk handling customer complaints during Glynis's surgery to protect his tenuous connection to health insurance.
8. Astronomical medical costs, such as chemotherapy sessions costing over forty thousand dollars, rapidly deplete Shep's Merrill Lynch net portfolio value.
9. Glynis shifts her focus from random misfortune to corporate fault by identifying historical exposure to asbestos products in her art school days, pursuing a contingency lawsuit.
10. Shep uses his remaining financial reserves and legal settlement to buy coastal land and build a home in Pemba after facing the final calculus of survival and release.