A Man Was Murdered in Cold Blood and You’re Laughing?, What the death of a health-insurance C.E.O. means to America, The New Yorker, Dec. 7, 2024, by Jia Tolentino

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The C.E.O. of UnitedHealthcare, fifty-year-old Brian Thompson, was murdered on the street in midtown Manhattan …

The public reaction has been wild, lawless. The jokes came streaming in on every social-media platform, in the comments underneath every news article. “I’m sorry, prior authorization is required for thoughts and prayers,” someone commented on TikTok, a response that got more than fifteen thousand likes. “Does he have a history of shootings? Denied coverage,” another person wrote, under an Instagram post from CNN. On X, someone posted, with the caption “My official response to the UHC CEO’s murder,” an infographic comparing wealth distribution in late eighteenth-century France to wealth distribution in present-day America. The whiff of populist anarchy in the air is salty, unprecedented, and notably across the aisle. New York Post comment sections are full of critiques of capitalism as well as self-enriching executives and politicians (like “Biden and his crime family”). On LinkedIn, where users post with their real names and employment histories, UnitedHealth Group had to turn off comments on its post about Thompson’s death—thousands of people were liking and hearting it, with a few even giving it the “clapping” reaction. The company also turned off comments on Facebook, where, as of midday Thursday, a post about Thompson had received more than thirty-six thousand “laugh” reactions.  …

The Norwegian sociologist Johan Galtung coined the term “structural violence” in 1969, in a paper that offers a taxonomy of violence—ways to distinguish between the forms that violence can take. … It can be manifest, or latent. Traditionally, our society fixates on only one version of this: direct physical violence committed by a person intending harm. …

On this point, though, everyone’s really in agreement. It’s just a matter of where you locate the decay—in the killing, or in the response to it, or in what led us here. The only way to end up in a situation where a C.E.O. of a health-insurance company is reflexively viewed as a dictatorial purveyor of suffering is through a history of socially sanctioned death. … Nurses, residents, aides, specialists—they are asked to absorb the rage and panic induced by the American health-care system, whose private insurers generate billions of dollars in profit and pay executives eight figures not despite but because of the fact that they routinely deny care to desperate people in need.

Of course, the solution, in the end, can’t be indifference—not indifference to the death of the C.E.O., and not the celebration of it, either. But who’s going to drop their indifference first? At this point, it’s not going to be the people, who have a lifetime of evidence that health-insurance C.E.O.s do not care about their well-being. Can the C.E.O. class drop its indifference to the suffering and death of ordinary people? Is it possible to do so while achieving record quarterly profits for your stakeholders, in perpetuity?

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I Am Torn: Grappling With the Killing of UnitedHealthcare’s CEO, MedPageToday, Dec. 10, 2024, by James Young, M.D.

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On the one hand, I shed no tears for Thompson. The man made millions off the suffering of others. More than $10 million last year, in fact. Likewise, every penny of the $22 billion in profit made by parent company UnitedHealth Group in 2023 was at the expense of the suffering of others.

I have no small amount of schadenfreude for what has happened to him. Sometimes, I even find myself wanting to crack jokes at his expense. Is Hell going to require a 2-night qualifying stay prior to admission? Does he have a skilled demonic need that would merit admission to Hell? Others have had similar reactions, posting online comments like, “Unfortunately my condolences are out-of-network,” and “Prior authorization is needed for thoughts and prayers.” …

I hate everything that Thompson stood for. I hate everything that his company stands for and will likely continue to stand for. I expect that the UnitedHealth Group PR and legal teams will use his death as an excuse to stifle any substantive debate or legitimate criticism about UnitedHealthcare with the mantra of, “We need to cool the temperature of the conversation,” or some similar, hollow PR statement.

And yet, I find myself troubled by jumping on the bandwagon of hate.

We need to take this opportunity to mourn the loss of another human being, taken by violence on our streets. We need to show compassion to his family.

We need to say with a single voice that we condemn the actions of Thompson and UnitedHealthcare as vehemently as we condemn the actions of his assassin. We need to warn that too many people — both patients and executives — will continue to suffer until insurance giants put the needs of the patient above those of the shareholder. While I don’t condone more killing or violence against health insurance executives, it’s not unlikely. In fact, it’s already happening. But it needs to be made clear that it’s not rhetoric or debate about insurance company malfeasance driving this action, but the companies’ own actions.

We as physicians need to be vocal, engaged, and seize this moment where the public is now engaged and the media watching, to make the case for why insurance in America is broken.

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Ben Shapiro Fans TURN ON HIM Over United Health CEO Take, The Kyle Kulinski Show (on YouTube), Dec. 9, 2024

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“It’s not left or right. It’s not black or white. It’s rich vs. poor.”

“Remember folks, Ben … knows exactly what he’s doing. He has more in common with the CEO than 99% of us. Radical change is not about the ‘left’ or ‘right.’”

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Comment:

By Jim Kahn, M.D., M.P.H.

In my line of work – quantifying the health effects of health policies and programs – every death counts similarly. Death by illness, medical neglect, accident, or murder is … a death. So I bristle when people tell me that a specific death is particularly egregious. True – untimely, unexpected, avoidable deaths carry a particular emotional weight. And age at death can matter in our calculations. But, ultimately, our standard metrics mean that 100 deaths are, roughly, 100 times as bad as one death.

Thus, I resonated with the widespread response to an insurance CEO’s death. Yes it was a tragedy. It seems like he was a nice man, not deserving of this fate.

However, the job he did – CEO of the largest private insurance group in the United States – made him a symbol of what is wrong with our health insurance.

Indeed, our entire broken insurance approach, built on a foundation of private insurance, generates massive clinical harm. Annual deaths due to lack of insurance are estimated at 40,000 – 80,000. COVID deaths linked to uninsurance topped 300,000. Annual deaths attributable to under-insurance are substantial but much harder to estimate: about half of all adults skip or delay care. My own calculation in HJM based on international data estimates >190,000 excess deaths attributable to our fragmented insurance.

We know this, yet we don’t fix it. Why not? Opposition from corporations and the elected officials they support and lobby. That’s systemic violence.

One caveat: As suggested in the various comments and commentaries, what UHC does wrong is care denials. Certainly, those denials are painful, and symbolic of a lack of caring. Yet they are often clinically inconsequential. Much of what we do in medicine (perhaps 20%) is not effective or even harmful, according to the National Academy of Medicine. We are desperate to try every possible intervention to stave off death. Thus, most care denials probably generate little clinical harm. As reviewed above, the real problem is massive gaps in coverage and access.

How can we fix this? Abandon our for-profit corporate approach to health insurance. In favor of a single, not-for-profit public payer, covering everyone with excellent benefits. As many other wealthy nations demonstrate, this saves resources and prolongs life. Let’s protect individuals (CEOs and others), but most of all let’s protect our population.

https://healthjusticemonitor.org…

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Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries, Commonwealth Fund, Dec. 4, 2024, by Munira Z. Gunja et al.

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Like several other countries, nearly all adults age 65 and older in the U.S. have health coverage. But high out-of-pocket costs in the Medicare program may still make it more difficult for older Americans to receive affordable care compared to older adults in other countries.

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Comment:

By Jim Kahn, M.D., M.P.H.

I just spent 3 days in Amsterdam, the Netherlands. Everyone seemed quite content. No wonder, given the extremely low prevalence of medical care cost barriers observed in this survey. Similar for most other nations included. The U.S. performs worst overall, by far, and worst or 2^nd worst on each measure. I’m beginning to think that uncertainty in the U.S. on medical care affordability is a major underlying cause of stress, anxiety, and the drive for political upheaval (more on that in a future post).

Now I’m in Nairobi, Kenya, at a meeting about addressing dementia in low-income countries. These nations face huge challenges not only for treatment and care, but also for prevention programming. Because … they have very little money. We in the high-income nations need to do a lot more to help them, and they should more emphatically prioritize heath in their budgets.

The U.S. doesn’t have the excuse of being poor. We have plenty of money – the most in the world. Our problem is that we build our massive health care system (fully 40% of global health spending) to benefit for-profit intermediaries and providers. This drives up costs. And insurance coverage is designed on the flawed premise of “skin-in-the-game” (empirically, it does not control costs). Lots of pain, no real gain.

Best practices, learning from successful approaches, following the leaders … whatever phrase you prefer, it’s long past due for the U.S. to adopt proven practices from peer nations – to assure access while controlling costs.

https://healthjusticemonitor.org…

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The State of Health Insurance Coverage in the U.S., Findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey, Nov. 21, 2024, by Sara R. Collins and Avni Gupta

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Survey Highlights:

More than half (56%) of U.S. working age adults were insured all year with coverage adequate to ensure affordable access to care. But there are soft spots requiring policy attention: 9 percent of adults were uninsured, 12 percent had a gap in coverage over the past year, and 23 percent were underinsured, meaning they had coverage for a full year that didn’t provide them with affordable access to health care.

Among adults who were insured all year but underinsured, 66 percent had coverage through an employer, 16 percent were enrolled in Medicaid or Medicare, and 14 percent had a plan purchased in the marketplaces or the individual market.

Nearly three of five (57%) underinsured adults said they avoided getting needed health care because of its cost. 44 percent said they had medical or dental debt they were paying off over time.

Delaying health care has health consequences: two of five (41%) working-age adults who reported a cost-related delay in their care said a health problem had worsened because of it.

Nearly half of adults (48%) with medical debt are paying off $2000 or more; half of those with debt said it stemmed from a hospital stay.

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Comment:

By Don McCanne, M.D.

When we discuss the problems with financing our health care system, many in the policy or political communities brag about the advances we’ve made through insurance coverage. But these increases have largely been through private insurer models that hamper access: There has been a sharp increase in the numbers of individuals in Medicare Advantage plans, which typically offer narrow provide networks while vastly overcharging the government through diagnostic upcoding and risk selection. States rely widely on private Medicaid intermediaries, which have significant provider network issues. Employer-sponsored private plans increasingly shift direct costs to employees through higher premiums, greater deductibles and copayments, and more aggressive prior authorization. Similarly in ACA marketplace plans. Thus, increased reliance on private plans is really an expansion of the problems that are peculiar to the private insurance industry, as revealed in the newest Commonwealth Fund Health Insurance Survey.

Promoters of these plans say that they are giving us freedom of choice by placing health insurance coverage in the marketplace, which touts competition as being an important mechanism for controlling costs. But look more carefully at the choices we supposedly have. Insurance category is dictated: Medicare by age or disability, Medicaid by poverty, employer sponsored plans by your job, or ACA plans or individual private market plans merely because no other choice is available. Many retirement plans mandate Medicare Advantage, and dropping physician payments in traditional Medicare undermine that option. Most of all, we have no choice about the higher non-clinical spending required by superfluous private insurance intermediaries, via profits, cumbersome administration, and administrative tasks forced on providers.

Besides, what choice do we really want? Don’t we really want free choice of physicians, hospitals, and other medical services – that would be available through an equitably funded, universal, public, single payer program, a program that belongs to all of us rather than just to the millionaires and billionaires, a program where all of our health care dollars are spent just on health care? I don’t think we really want a choice of private plans that are designed specifically to use what should be our health care dollars to create greater wealth for the intermediaries that find innovative ways of diverting our funds away from health care?

Look at the choice we made through the recent election. We elected a president who is choosing administrative personnel who intend to eliminate our traditional government Medicare program that is free of private carriers, and replace it with a universal private Medicare Advantage program which has already been demonstrated to divert hundreds of billions in health care dollars to their private industry. Furthermore, our president-elect has brought in the richest man in the nation who intends to manipulate our government in a manner that will make him the world’s first trillionaire. Is that the choice that we want? giving our health care dollars and other funds to the wealthiest individuals in our nation, while leaving out many of those with genuine health care needs that are inaccessible to them under our current system so reliant on private insurers?

Let’s give everyone the freedom of choice in selecting the health care that they need and want instead of having false choice of which intermediary is going to take much of our health care dollars away and leave too many of us without the health care that we need.

What is our choice to be? Profits over patients? Billionaires over health care budgets? Or patients over our own health care system that is designed to take care of everyone? It doesn’t seem like that is a very difficult choice.

https://healthjusticemonitor.org…

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Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Forum, Oct. 26, 2023, by Larry Levitt and Drew Altman

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Lack of insurance coverage, high costs, and poor outcomes are well-documented problems in the US health care system, and policies to address them have been hotly debated for decades. However, complexity is another under-appreciated problem that hinders access and affordability.

Almost 6 in 10 people with insurance reported a problem with using their health insurance during the past year (2022). The share increases to two-thirds of people in fair or poor health, three-fourths for those who need mental health services, and almost 8 in 10 for people who use the health system the most. The result is that many delay or skip care or accumulate bills they cannot afford.

The reality is that many people are hopelessly confused by how their insurance works. In Medicare, beneficiaries can now choose from an average of 43 private Medicare Advantage plans, and during open enrollment season, the airwaves are flooded with ads that may do more to confuse rather than illuminate. And people getting ACA coverage through healthcare.gov have a choice of more than 200 plan options on average. The complexity of too many choices can also lead to paralysis on the part of consumers.

Yet, any push for health care simplification inevitably clashes with commercial interests. The system is structured to simultaneously maximize profits, control costs, and serve customers, which are competing goals that add to the challenge of simplifying it.

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Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Although Health Justice Monitor commented on this article a year ago, political developments have not only failed to provide significant improvement in our expensive but underperforming health care system, it appears that the malfunctioning of our system will only become worse.

We have been increasingly reliant on private insurers as demonstrated by the increase in conversion of traditional Medicare to private Medicare Advantage plans and the greater reliance on commercial plans through the Affordable Care Act. So we are spending ever more of our health care dollars on an industry with a mission that places a higher priority on diverting health care dollars to private investors instead of directing all of those dollars to achieving comprehensive health care for everyone.

We have an abundance of health policy research that demonstrates that the defective private insurance model increases costs and decreases access to care. It should be eliminated and replaced by a public single payer program that would, by design, not only provide health care for absolutely everyone, but also control costs while improving the allocation of health care dollars. That model would be similar to traditional Medicare except that it would offer more comprehensive benefits, eliminate cost sharing that currently causes financial hardship, assure free choice of providers and facilities, and equitably finance via progressive taxes which would be affordable for everyone without materially diminishing the lifestyles of the wealthy despite their paying more (they can afford to!).

In our recent presidential election, one of the major parties emphasized neoliberal policies which eliminated any consideration of the superior single payer model, instead supporting small incremental changes which would have negligible impact in healing our sick health care system. The other major party vaguely promised system improvement but hinted major cuts in public spending. They also selected individuals as likely heads of HHS and CMS who would shred the program that we have at a cost of lives, health, and worse financial hardship for patients.

Wouldn’t it be better set aside politics, and instead adopt policies that provide definitive solutions to the problems of high personal health care costs and financially squeezed providers? We have ample examples from countries of varied political leanings of how to use funds well.

Shouldn’t we encourage our legislators, all of them, to join together to approve a system that would work so well for everyone? Now that we have an incoming president who would like to take personal credit for radically redirecting government to serve the public, maybe we have a chance.

https://healthjusticemonitor.org…

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Comment:

By Jim Kahn, M.D., M.P.H. and Don McCanne, M.D.

First, sincere apologies for the two-week lapse in HJM postings. We were consumed with worry leading up to the election, followed by shock and despair with the result. For those of us on the Left, the upcoming period is fraught with major socio-political risks and challenges. HJM readers no doubt feel similar intense and complex emotions.

Where does HJM fit into this new and fraught political environment? We’ve been contemplating this tough question.

Without a doubt, we need to keep monitoring the performance of current health insurance, which is likely to deteriorate with pursuit of the Project 2025 health policies. Other advocates do that exceptionally well, including HEALTH CARE un-covered on private insurer misbehavior, JustCare on Medicare issues, and PNHP laser-focused on Medicare Advantage.

HJM will still highlight discussing research and policy news that reveals the inefficiencies and inequities of our fragmented insurance system. We will, as always, get geeky in the interest of understanding the dynamics behind the news, and of making connections between issues. We will always analyze and educate about single payer / improved Medicare-for-All.

And, we will increase our attention to front-and-center political issues: How does single payer help us meet the current challenge to US democracy? How can single payer broaden support for progressive policies? How can it help heal the left-right political rift, by demonstrating the compatibility of efficiency and equity? How can we best convince skeptical right-leaning audiences of the common sense of single payer?

We welcome HJM reader input on refining our mission. What do you most value in HJM? What topics would you like us to address? How can we best support the struggle for health care justice, and invigoration of American democratic ideals? You can reply to the HJM email, or email healthjusticemonitor@gmail.com.

https://healthjusticemonitor.org…

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Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.