What The Reaction To The UnitedHealthcare CEO’s Killing Tells Us

The question of who killed UnitedHealthcare CEO Brian Thompson ― and why ― is going to take a while to answer definitively, even if police in Pennsylvania now have a “person of interest” in custody. The question of how Americans feel about the health insurance industry, on the other hand, leaves little room for doubt.

On social media and in everyday conversations, Americans have joked about last week’s shooting in New York ― and in some cases even suggested that Thompson deserved to die ― because of what they say his company and his industry have done to stop people from getting health care.

As HuffPost’s Jennifer Bendery and Arthur Delaney reported last week, lots of people wrote variations on “thoughts and prayers are out of network,” invoking a familiar piece of insurance terminology. Under an item where New York officials sought tips on finding the killer, one commenter said “my regular insurance doesn’t cover vision so I can’t really see” while another wrote “we need prior authorization first” — once again, using insurance company lingo.

You don’t have to be a corporate shill to find that reaction dehumanizing and disturbing. Taking satisfaction in somebody’s killing feels like the sort of thing that was clearly out of bounds before social media made it easy for people to express their worst instincts aloud and then be rewarded for it with even more attention.

“In some dark corners, this killer is being hailed as a hero,” Gov. Josh Shapiro (D-Pa.) said in a Monday news conference detailing the latest developments on the case. “Hear me on this: He is no hero. … In America, we do not kill people in cold blood to express policy differences or a viewpoint.”

But you also don’t have to condone the online reaction, let alone the killing itself, to understand where it came from or why somebody associated with the insurance industry would inspire such hostility. And you don’t have to think commercial insurers are primarily responsible for the problems of American health care to spot the role they’ve played in its well-documented dysfunction.

That role starts with the limits on medical care that have been the reference point on social media for the past week.

More than half of Americans with private insurance say they’ve had trouble using their coverage ― like running into treatment denials or struggling with small provider networks ― according to polling from KFF, the California-based health care research organization. The number is even higher for those who say they have health problems, which suggests the people most likely to encounter these obstacles are the ones who need health care the most.

These obstacles have existed for a while, and this is not the first time outrage over them has spawned a broader conversation about whether to curb insurance industry behavior. Back in the late 1990s, Congress spent several years debating whether to pass a “patient’s bill of rights” that would have given everyday Americans more power to challenge treatment decisions and even sue insurers in court.

You could tell the idea was popular by looking at the polls, which showed strong support from across the political spectrum. Or you could just go to the movies. In a key scene from the 1997 film “As Good As It Gets,” a main character played by Helen Hunt cursed insurers as “fucking … bastard pieces of shit” because they had denied tests and treatments for her asthmatic son. Audiences around the country broke into spontaneous applause.

At the time, the insurance industry and its allies argued that their limits on care were cutting down on unnecessary, sometimes harmful treatments that people didn’t really need — and, more importantly, holding down the cost of health care. If not for tools of what became known as “managed care,” insurers said, Americans would have to pay even more when they went to the doctor’s office, hospital or pharmacy, and many would have to skip care altogether.

Insurers and their allies make the same arguments today. And they are not exactly wrong when it comes to the deeper problems of American health care or the role insurers can play in addressing them.

There are reams of data to suggest the system is ripe with mistreatment and over-treatment, and that the main reason American health care costs so much is that the providers and producers of care have so much power to set such high prices.

In fact, the origins of managed care lie in efforts to promote a more holistic approach to medicine, one in which doctors would work on salary rather than be paid for each procedure, focusing on prevention and coordinating with each other on treatment plans. Early versions included a nonprofit cooperative in rural Oklahoma and the shipyard medical clinics that industrialist Henry Kaiser established for his West Coast employees during World War II.

Decades later, it was a pediatric neurologist named Paul Ellwood trying to improve rehabilitative care for his patients in Minnesota who promoted managed care as a new model for health insurance. He called his version of the setup “health maintenance organizations” because he hoped they would focus on keeping people healthy.

You can still see vestiges of that approach in organizations like Kaiser Permanente, the nonprofit descendant of those shipyard clinics. And while it’s hard to quantify insurer performance, one telling measure is the rate of treatment denials — which for Kaiser, according to a recent report from the website ValuePenguin, is just 7% of claims.

But the industry average is 16%. The industry leader at 32% is UnitedHealthcare, the company Thompson led.

And it’s not just the volume of denials raising questions about the conduct and priorities of big commercial insurers. It’s the nature of the denials, which have come to light through legal proceedings, congressional testimony and journalistic exposés. Among the latter was a monthslong ProPublica investigation of algorithms and other tools United was using ― as the report put it ― to “police mental health care with arbitrary thresholds and cost-driven targets.”

United told ProPublica its practices were “an important part of making sure patients get access to safe, effective and affordable treatment.” Providers, patients and mental health care advocates who the reporters quoted in the article disagreed, arguing the limits routinely deprived people of care they needed.

That is the very same thing Miranda Yaver, a health policy professor at the University of Pittsburgh, found in her research for a forthcoming book about American health insurance companies and the ways they restrict treatment.

“I surveyed and interviewed many, many patients whose condition worsened because of their inability to get approval for a prescribed medication or procedure, resulting in either reliance on less optimal treatments, hospitalization, or even cancer recurrence,” Yaver told HuffPost in an email.

And while it’s possible to challenge insurer denials, Yaver noted, not everybody has the time and money ― or knowledge ― to do so: “Patients from more marginalized groups have a harder time weathering this storm, so they appeal less frequently and with less success, keeping care out of reach and worsening inequities along the way.”

Yaver agrees there’s widespread evidence of misguided or unnecessary care in American health care, not to mention prices that dwarf peer nations. But in those other countries prices are lower because they have national health insurance systems holding them down.

In practice, that can mean governments providing insurance directly or tightly regulating sets of competing private insurers. The constant is that governments control spending in a different way — by dictating prices, setting overall national budgets or some combination of the two.

That approach comes with its own tradeoffs and potential drawbacks, including more explicit rationing of treatments if and when public funding falls. The potential for that to happen here in the U.S. is among the more powerful arguments that political conservatives as well as industry lobbyists make against enacting sweeping reforms.

But rationing already happens in the U.S., whenever people who need care can’t get it. And overall, according to international surveys by the Commonwealth Fund, people in other countries struggle with cost and care less than their American counterparts ― in part because the lower costs in those places make it possible to finance insurance for everybody, so there aren’t large numbers of people with no coverage at all.

Reformers have been trying to create a system like that here in the U.S. for nearly a hundred years. They’ve never been able to overcome the political opposition.

Whole books have been written on the complex story of why this kept happening. A big, politically inconvenient part of the saga is that most Americans have health insurance and, notwithstanding their feelings about the industry as a whole, are wary of giving up what they have.

But another big part of the story is the opposition of industry groups that profit from the status quo. That very much includes health insurers, who eagerly joined the fight against Harry Truman’s national health insurance proposal in the late 1940s, led the charge against Bill Clinton’s ill-fated universal coverage plan in the early 1990s and pushed back on the (far more modest) reforms that eventually became the Affordable Care Act, aka “Obamacare,” in the late aughts.

The insurers’ motive, according to former insurance industry executive Wendell Potter, is not hard to discern. “Those of us in the insurance industry constantly hustled to prevent significant reforms because changes threatened to eat into our companies’ enormous profits,” he wrote in a 2020 New York Times op-ed.

Potter, who after leaving Cigna became a prominent advocate for health care reform, told HuffPost he thinks that today “insurers are using prior authorization much more aggressively and frequently than ever before.” And while he too acknowledged the need to control costs, he pointed out that the whole process of scrutinizing treatments in the way American companies do can be its own source of added costs.

“It makes it necessary for doctors and hospitals and other providers to have staff who do nothing more every day than deal with insurance companies in attempts to get paid and to be able to treat their patients as they need to be treated,” Potter said.

The data backs up that claim: Administrative costs in the U.S. health care system are the highest among economically advanced counties. The same goes for the salaries of American insurance executives that at the high end of the scale can exceed $20 million a year.

Again, none of that justifies celebrating one executive’s slaying, let alone the killing itself. And depending on your political priors, it may not even justify forcing insurers to change their behavior. But making the case that their practices are beneficial means convincing skeptical Americans who were clearly angry at insurers before Thompson’s killing and are unlikely to change their feelings any time soon.