The deep roots of Americans’ hatred of their health care system

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The shooting of UnitedHealthcare CEO Brian Thompson was met by many people online with a morbid sense of inevitability. The often callous nature of the US health care system has long been a point of wide discussion, with evidence piling up that the way the country provides medical services is costly in both money and human life. The health industry’s executives — insurers, pharma, even hospitals — have become popular villains. 

The killing of a human being is morally repugnant — full stop. But many people still found themselves asking: If it turns out, as may well be the case, that the shooter was primarily motivated by the injustices of American health care, would that be surprising?

On the same day as the shooting, news that a different insurer would restrict coverage for anesthesia during surgeries went viral, serving as a kind of cosmic confirmation of this line of thinking. A health insurance executive is shot in New York City over (it is assumed) the industry’s avaricious practices, while another insurer affirms the worst stereotype with such a seemingly arbitrary limit on people’s benefits to be given anesthesia during surgery.

The reality, however, is more complicated. As Vox’s Eric Levitz covered, this policy would not actually result in higher bills for patients; it is instead the kind of cost control that policymakers will often vouch for when public attention is elsewhere, something meant to rein in high payments to health care providers. But public and political outrage didn’t stop to make that connection, and the insurer quickly reversed the policy.

Put every aspect of this tragic episode together and you have the rotten core of American health care. The cruelties of the US medical system and the ongoing blame game between the private industries that profit from it have left patients angry and confused — and looking for someone, anyone, to blame, fairly or not. 

There is not one man nor even one industry responsible for the failures of US health care. The finger-pointing is a distraction. Every party bears responsibility. The only way forward is to reckon with that collective failure. We need to begin working toward a more rational and just system if we are to have any hope of creating a world in which Thompson’s shooting would be truly unimaginable.

The distracting health care blame game

At the dawn of the modern American health care system, the private industries that compose much of the medical sector were allies. 

Physicians in particular were fierce defenders of private insurance in the middle of the 20th century. The American Medical Association and its compatriots greatly preferred the country to cover most people through private employer-sponsored insurance over a government program and fiercely lobbied to smother the latter in the crib. They tolerated the creation of Medicare and Medicaid in 1965 to cover populations that were otherwise uninsurable, but would come together again to stop the Clinton health reform effort in the 1990s.

Everybody involved was invested in maintaining a free-ish market system. Hospitals and pharmaceutical companies could raise prices, and the insurance plans could pass on those increases to employers, whose health benefits were tax-free thanks to Congress, which made those hikes more tolerable. Medicare and Medicaid limited their spending, but the private portion of the market created the opportunity to increase profits, and they stuck together whenever the status quo was threatened. At least for a while.

But prices have continued to spiral upward, accelerated by the aging of the baby boomers and by important but costly advancements in medical science. Today, as everyone knows, health care in the US can be prohibitively expensive even for people who have insurance. Almost four in 10 Americans say they have skipped necessary medical care over the costs, and millions carry medical debts from past cases.

The passage of Obamacare over industry opposition was the first sign that the private sector’s political vise grip was loosening, with the Obama White House successfully dividing the industry against itself, targeting insurers and hospitals for cuts while in effect buying off pharma’s opposition. The more recent Inflation Reduction Act contained a provision allowing for Medicare to negotiate prices with drugmakers, which would lower costs and allow the program to cap seniors’ out-of-pocket costs. That would have been unthinkable a generation earlier when Big Pharma lobbied Congress to prohibit such a policy. Lawmakers of both parties continue to look hard at how to overhaul the health system to reduce costs.

That political realignment has turned the insurer, pharma, and hospital industries against each other. I have been covering health care for more than a decade, since shortly after the ACA passed. The battle lines have become clearer over that time, to the point where every sector is blaming the others for patients’ frustrations with the medical system:

• Hospitals blame drug companies (for charging high prices that they must pass on to payers) and insurers (for restricting benefits and leaving patients exposed to uncovered bills)
• Drug companies blame insurers (for charging patients high out-of-pocket costs for medications) and hospitals (for exploiting technical programs like 340B to artificially boost their profits); they also blame the pharmacy benefit managers (PBMs) who coordinate among drug manufacturers, plans, and pharmacies
• Insurers blame hospitals and drug companies (for charging too much money for their services and products, which patients bear through higher premiums and out-of-pocket costs)
• Patients blame everybody (for the high costs they face and the hassles of navigating this complicated system).

That is how you end up with misguided outrage over Anthem’s anesthesia policy. The doctors paint it as insurers cracking down on patients, when it is actually the plan trying to lower its overall costs and thereby save patients money. It becomes hard to do anything to reduce costs, leaving the frustrations with the system to metastasize until we see what we saw after the killing of UnitedHealthcare CEO Brian Thompson.

The collective failure of US health care

To be clear, health insurers have earned plenty of scorn. Before the ACA, they would simply refuse to cover people with expensive medical conditions. They are more constrained now that the ACA is law, but there is a constant stream of new reporting on novel tactics by insurance plans to deny patients coverage. They’re even using AI to do it. UnitedHealthcare has been the subject of recent ProPublica exposés for, among other examples, the company’s use of algorithms to deny claims for mental health services.

The same goes for drugmakers, who are sitting on the sidelines for the moment. There are some merits to their criticisms of health insurers, PBMs, and hospitals and how those entities pilfer money in the drug reimbursement process. But pharma companies also overstate how much the high prices they charge are necessary to fund research and development for new cures. They deflect when pressed on how they exploit loopholes in patent law to keep their monopolies on prices for popular medications like the diabetes drug Humalog.

The insurance and drug industries are right to cite hospitals and physicians as the biggest drivers of US health care costs. Most doctors are very generously compensated, and they have limited entry into their fields, which reduces the number of doctors and makes health care harder to access and more expensive per patient.

Yet providers have their own justifiable complaints about how health insurers deploy their networks to restrict coverage, such as prior authorization and other bureaucratic hurdles that providers must jump in order to receive compensation for caring for their patients. US doctors may make more, but they also spend more time and money on administrative tasks than their peers in other countries.

And round and round it goes.

People are fed up. The health care industry enjoyed a brief spike in popularity during the pandemic, but its approval rating as measured by Gallup has fallen back to 31 percent, with 51 percent disapproving. The share of Americans who approve of the quality of health care available to them has fallen to an all-time low. Only 18 percent of the American public views the pharmaceutical industry favorably; 60 percent hold a negative opinion. Most people say they’re happy with their insurance plan, but they are less likely to approve of their coverage if they have high bills, and most people still report problems using their benefits, according to KFF.

Providers enjoy the highest approval ratings, which may be why many people instinctively opposed the Anthem policy. But while the US public remains mostly fond of nurses, its opinion of doctors and hospitals has been dropping: for physicians from 81 percent in 2003 to 69 percent in 2023, for hospitals from 70 percent to 58 percent in the same period. The passage of the No Surprises Act, which targeted hospital billing, was a sign of their political clout softening.

The failure of American health care is a collective one, the result of the system being pulled together haphazardly over many decades, rather than thoughtfully planned from the start. Even the public often has contradictory desires, wanting both more choice and guaranteed coverage. The conflict between those two impulses helps explain the difficult struggle to reform US health care and the history of voters punishing politicians who do try to change the system.

There has been some progress. The uninsured rate remains too high, but it is about as low as it has ever been after a decade of the ACA. Medicare can negotiate drug prices, and seniors’ out-of-pocket costs for medications are now capped for the first time. 

Much more work needs to be done, and it will require cutting through the industry’s finger-pointing: Every sector demands some kind of reform. 

Only by looking at the system as a whole and figuring out how to make it economically viable while also providing necessary care for all who need it can we save this system that has fallen behind those of other rich nations. There are many different ways to achieve a version of universal health care. The US still has to decide that is in fact what it wants, as every other developed European and Asian country has. Many of their people have no concept of a world in which people go bankrupt over medical bills, something that is an everyday reality in the US.

No one person is to blame for all of the nation’s health care problems, not even a CEO. These issues were festering long before most of us were born. No one person has all of the answers either. But it has long been clear that the overall system is deeply flawed. There must be better policies across all the industries that make up what we call the American health care system to fix it.