Nobody asked me…

The killing of UnitedHealthcare CEO Brian Thompson has shocked many, bemused some, angered others, and brought all of us back to the decades old habit of lambasting private health insurance companies. There have been jokes about preexisting conditions and prior authorizations, hypocritical reminders from politicians about violence and politics, and patronizing lectures about how insurance companies are just doing the jobs we asked them to do: make money.

So who is the bad guy here? Is it Luigi Mangione, who seems to be the mysterious assailant who murdered Brian Thompson in cold blood? Is it the callous public, making a mockery of a horrific public crime in order to express their fear, anger, and anxiety over the inequities in the American healthcare system? Is it Brian Thompson, who was being investigated for insider trading and led UnitedHealthcare to record profits by emphasizing a claims denial rate that was twice the industry average?

To be honest, I’m indifferent to the villain in this particular melodrama. I am not entirely alone in my indifference. Jia Tolentino writes in the New Yorker:

“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?”

Here is where my indifference disappears: the healthcare system that we’ve created, the one that existed before Brian Thompson became CEO, and that continues to exist now, after his death. In fact, we’ve been trying to reform this hodgepodge and inefficient system since before Brian Thompson was born. I work in this system and it is expensive and ineffective at promoting our health. By almost every measure we spend more money on worse health system performance. The system doesn’t take care of everyone. It is broken.

If we destroy all health insurance companies, hypothetically massacre all of their CEOs one by one, will the system be better off? I mean, health insurance companies are bad. They are incentivized to maximize profits by denying claims and they support a system of segregated care where rich and healthy people fare just fine and the poor and vulnerable are left to die while waiting on hold. 

But hospitals are also bad. Growing conglomerates of healthcare providers are also incentivized to make as much money as possible, which is not accomplished with altruism and certainly not by compassionate care alone. Acadia Healthcare is one of the largest hospital systems in the country and routinely contracts with other providers. In the last year alone, it has been revealed that they have exploited vulnerable outpatients in their methadone clinics with fraud and insufficient care and held inpatient psychiatric patients against their will in order to maximize insurance payouts. In fact, on average, hospitals have profit margins twice that of insurance companies. Who’s the supervillain now?

You may note that a few other bad guys emerge in the bar chart above. Pharmaceutical manufacturers and medical device companies are both absolutely running away with it. They might as well be carrying giant canvas sacks marked with a dollar sign. They frequently manipulate patent law and capitalize on publicly funded research to maximize their own earnings, while ruthlessly advertising to the general public and overwhelmed physicians about their products and new technology.

Speaking of physicians, we do not emerge unscathed from this blood bath either. Besides our embarrassing historical track record of opposing national healthcare reform and shortsightedly focusing on maximizing our own income, we continue to spend much of our national organization lobbying dollars on increasing our own reimbursement instead of fixing the broken system that we helped to create. We routinely offer and provide low-value healthcare because it’s easier than discussing complexities with demanding patients.

And those demanding patients! You all want the most expensive, state-of-art, cutting-edge, unproven care we can give you, even if it won’t help. You’re not paying for it anyway. Your undertaxed, employer health insurance plan is. We’re all sort of the bad guys!

But bad guys aren’t all bad, right? Patients are just trying to take care of themselves and their families and many are forced to pay lofty premiums for high-deductible plans that deny all of their claims anyway. Even the rich folks with the Cadillac insurance plans are scared and vulnerable when they’re sick, just like the rest of us. If the doctor thinks it might help, we want to try it. And how can you blame the overworked physicians who wasted 11 or more of their prime years on medical training? Many of us work for non-profit enterprises and just want to help people. We can’t do that without getting paid! It’s not our fault if the system incentivizes tests and procedures over care and consideration.

What about those medical device and drug companies? Don’t they provide most of the research and development for the world? Over half of the world’s new drugs were first launched in the United States. Don’t people from all over the globe come to the United States for cutting edge, over-the-top, state-of-the-art care? They can’t be all bad! Maybe they deserve those profit margins. And while we’re talking about profit margins, those poor insurance companies are only taking a meager 3-4%. Plus, they’re the only actor in the system with an incentive to reduce healthcare spending. Someone has to be the grown up and say no sometimes, right? Can we blame them for that?

Maybe there is no bad guy. Some guys may be worse, but we’re all a part of the problem now. We’ve created a system that requires everyone to maximize their own well-being at the expense of others. That system may be fine if you’re manufacturing television sets but becomes increasingly less civilized as we approach life and death. What is the goal of our healthcare system? Is it to make the most money for select corporations? Is it to provide unlimited healthcare, medical devices, and pharmaceuticals for everyone and anyone who wants them? Is it to cater to foreign dignitaries and wealthy business leaders? Is it to maximize our collective health and longevity? At what cost? 

There are numerous cultural, political, and logistical barriers to health system reform but they are not impossible to overcome. They will require each of us to examine our role in the system. We have to let go of some of our zeal for individualism. Some of us have to be willing to consume less healthcare and have worse insurance coverage so that we can all thrive. We have to worry less about how much money we’re all making and be more worried about stewardship of our societal resources. We’ll have to sacrifice a little and compromise a lot. 

For my part, I’m going to start writing about health policy again. Business practices can be very effective in the right setting, but relying solely on business practices to deliver healthcare is antithetical to health equity. But we also can’t ignore basic economic principles if we’re going to effectively redesign this complex system. And we all need to understand enough about this dystopian reality to not be swayed by the well-funded propaganda of our corporate oligarch overlords. We have to stop whining about the supervillains and start trying to be the good guys.