Dark Times for Public Health and Healthcare: Will the insurance industry fix itself?

It’s an exciting time for both health care and public health! Anything goes, and almost anything is, or will in the near future! On the public health front, we have the nomination by President-elect Trump of Robert Kennedy, Jr. to the post of Secretary of Health and Human Services. Kennedy has long been what is generously called a “vaccine skeptic” and his lawyer, Aaron Siri, has sued the Food and Drug Administration to revoke the approval of the polio vaccine. Although the NY Times article says ‘Like Mr. Kennedy, Mr. Siri insists he does not want to take vaccines away from anyone who wants them. “You want to get the vaccine — it’s America, a free country,” this is disingenuous. If the FDA approval is revoked, nobody will be able to get it.

I have written recently about the importance of vaccines, especially polio and measles, in preventing disease and death (Raw milk, vaccines, and RFK, Jr: Some dates worth remembering, Nov 15, 2024). A series of letters to the Times in response to the Siri article make clear the risk. Read them; they address the science, the controlled trials of polio vaccine, the experience of those who were doctors and children during previous polio epidemics, and touchingly, the experience for dancer Tanaquil LeClerq, wife of choreographer George Balanchine (short answer: no vaccine, polio, and paralysis). In regard to other vaccines, we can read in the Times ‘Tiny Coffins: Measles Is Killing Thousands of Children in Congo’ and imagine it happening in the US as a result of Kennedy’s anti-vaccine actions. Kennedy calls his movement “health freedom” and says that he will give infectious diseases a “break” (whatever that means), but in fact, as described by Gregg Gonsalves in The Nation, RFK Jr. Is Giving Infectious Diseases a Promotional Tour.

I posted on Facebook that I have heard people say “kids get too many shots”, and asked “then which preventable disease do you want your child to die of?” One comment I got from a colleague was that the problem was not that kids get too many shots, but that too many kids get shot! The most recent killings, in a Christian school in Madison, WI (15-Year-Old Girl Identified as the Shooter in a Wisconsin School) were at least the 323^rd this year in the US! THIS is an epidemic, the extent of which people in most other countries cannot imagine, and, like many of us, wonder what will be done about it. Sadly, the answer is going to be very little, if anything; we may be closing out the statistics for deaths from school shootings in 2024, but nothing suggests that 2025 will be any better.

On the healthcare front, things are not getting better. The anger at the health insurance industry exposed by the shooting of UnitedHealthcare CEO Brian Thompson was deep, broad and well-justified, as I wrote in Murder of a Health Insurance CEO: People HATE the companies and the people who run them (Dec 8, 2024). Study after study continues to appear providing evidence that more and more people that have inadequate, unaffordable, or no health insurance. The Commonwealth Fund recently published a report that shows Hispanic/Latino Adults Lack Adequate, Affordable Health Insurance Coverage,

and that this led to their having real trouble accessing health care, but the breadth of this lack goes far beyond Latinos.

Maybe we can come up with a solution! I think I have already indicated several – mainly instituting a single-payer universal national health insurance program. Or, until we do, capping the amount of out-of-pocket costs a person can have to a reasonable number ($1000?). And limiting the profits of health insurers, or the ways in which health care providers (e.g., hospitals mainly, but also nursing homes, doctors, etc.) act to make money whether technically profit or “non-profit” at the expense of people’s health.

Others have entered this discussion. In a remarkable Op-Ed essay in the NY Times on Dec 13, UnitedHealth Group’s CEO Andrew Witty (Brian Thompson’s boss, who makes more than $20M a year) wrote The Health Care System Is Flawed. Let’s Fix It. Unfortunately, what is remarkable is that the Times chose to run it at all, since it makes no significant suggestion on how to “fix” it, certainly none that would threaten UnitedHealth’s profits. It mostly displays the Times’ complicity in an effort to focus away from the righteous fury of the American people with the health insurance industry.

USA Today reports on Seven reasons why Americans pay more for health care than any other nation, and it gets most of them right. (Reason 1: Lack of price limits, Reason 2: Hospitals and doctors get paid for services, not outcomes, Reason 3: Specialists get paid much more ‒ and want to keep it that way, Reason 4: Administrative costs inflate health spending, Reason 5: Health care pricing is a mystery, Reason 6: Americans pay far more for prescription drugs than people in other wealthy nations, Reason 7: Private Equity.) There are a few others, but it is a good list. Despite that, however, it doesn’t come up with a meaningful, comprehensive solution to them, or any of them. Indeed, it ends up quoting the Witty piece referenced above, "We know the health system does not work as well as it should, and we understand people’s frustrations with it,” rather than having any kind of answer. Like, say, universal non-profit health insurance, limits on hospital system (and physician) incomes, and banning private equity and other for-profit players from the health system!

Maybe it is asking a lot for insurance companies, largely the perpetrators of this massive scam that is bleeding the entire US economy, to come up with a “solution”. But USA Today, Commonwealth Fund, and others that do such a good job of identifying the problem should be able to take the simple next step to recommending the fix. In what is to me an amazingly open (if entirely disgusting and reprehensible) acknowledgment of their agenda, CNBC reported back in April 2018 that Goldman Sachs, the huge investment bank (Jamie Dimon, CEO) raised the question (discussing biotech research) ‘Is curing patients a sustainable business model?’.

!!??

Actually, it’s a good question. Maybe the answer is “no”. Most ethical physicians I know (and it is the vast majority who are ethical) have always said something like “I look forward to the day when we can put ourselves out of business”. Investment banks and other forms of private equity, and the insurance companies like UnitedHealth and the providers that they control, do not see this as a positive. Maybe it is refreshing to see such a stark portrayal of the problem? Or not.

But I, and I believe most Americans, would rather see diseases and the people who have them cured, and would be happy to see the profits of any of these profiteers, privateers, just plain ganevem, and the salaries of their C-suite execs and Boards, disappear.

Murder of a Health Insurance CEO: People HATE the companies and the people who run them

A few days ago, Brian Thompson, CEO of UnitedHealthcare, was murdered on the streets of Manhattan outside the New York Hilton, where a stockholders’ meeting was to take place. Some newspaper articles referred to it as an assassination. I’m not sure what the difference is, but I think assassinations usually target someone famous or important, and often have dramatic results (think WWI after the assassination of the Austrian Archduke, or JFK). Thompson may not have been particularly famous, but he was important, being in charge of one of the largest health insurers in the US and a leader in denying claims. Thompson himself is credited with instituting (he probably didn’t actively develop) a system using artificial intelligence (AI) to deny claims.

Most people, patients and physicians, don’t like having a claim for their medical treatment denied, whether by AI or a human being. In general, insurance companies denials are first done by a lower-level employee (or even, as at UnitedHealth, AI). Then if it is appealed by the patient or the physician (which it often, even usually is not, because it takes time; this is what the insurer counts on) it may go to a physician reviewer to decide. That physician does not necessarily have the expertise to make a medical decision regarding the treatment, and often doesn’t, but is strongly motivated by various insurance company practices to deny. These practices include pressure to review lots of cases, to deny a certain (high) percent, and bonuses for high denial rates, which have been well-described by many former physician reviewers (e.g. https://kevinmd.com/2021/10/for-doctors-leaving-clinical-practice-consider-utilization-review-jobs.html) and former health insurance executives like Wendell Potter.

The “principle” behind delaying and denying claims is that this makes them more money, so there are people who think it is good -- the owners and executives of insurance companies – if they can be assured that their privileged position means that it will not happen to them or to their families when they are sick. We read that the cartridges found from the assassination had words including “deny” and “delay” scratched on them; this is pretty good evidence that the killer was motivated by the same angry frustration that so many of us have, even if we would not commit murder. To be sure, Thompson – and his ilk, it is not just him, and he will be replaced by another heartless monster – were also murderers, killing hundreds or thousands by denying the care that their doctors said they needed. We imagine that if the killer is caught, we will find out that his child or spouse died as a result of such UnitedHealth action. It is, frankly, unconscionable and is a system that does not exist in other countries.

The almost unanimous reaction that people have had to the murder exposes the depth of the hatred we have of the health insurance industry and the system of denial and delay that is at its core. While few would commit or even condone murder, there is an almost universal feeling that Thompson was a really bad guy. The extent and breadth of this reaction is, I think, much greater than that leaders of insurance companies and their stockholders and the politicians in their employ expected. I mean, they don’t think that they are really bad guys (and note that several of the health insurance CEOs are women). They just think that they are doing their job, and following the dictates of capitalism, making the most money possible for their companies. And, yeah, getting well paid for it (at about $10.2 million in 2023, Thompson was not even in the top tier of “healthcare” CEO pay, many of whom made over $20 million, including his boss at UnitedHealth Group, Andrew Witty). We even see posts like the one below describing a sudden (although, I am certain, quite temporary) drop in denials in the last few days.

I have written about the benefits of single-payer universal health, the usual standard in every other developed country in the world, often. I have urged eligible people (mostly seniors) to take advantage of and enroll in one of the few single payer opportunities that we have, traditional Medicare, rather than put themselves back into the mercy (as if!!) of the private for-profit health insurance industry by opting for Medicare “Advantage” (UnitedHealth insures about a third of MA patients). I have recently also noted that, short of this, we could cap the amount of out-of-pocket cost that anyone could be liable for to a reasonable amount (Health Insurance is not Healthcare: Everybody in, nobody out!, November 23, 2024). I add that what could be done now would be to make profit in health insurance illegal. Think what that would drive! As I noted in that Nov 23 piece, in places like Switzerland there are competing insurance companies, but they are highly regulated, have to provide the same benefits, charge the same prices, and cannot make a profit – so, amazingly to us, compete on customer service!

Note to health insurance company executives: people HATE you. They really hate you. They hate you worse than thieves and murderers because you are effectively that on a grand scale. We may disapprove of thieves and murderers in the abstract, but especially if they steal from or kill someone we know or love; health insurance companies have spread the impact of their evil far and wide. People may, like me, not advocate killing you in the street but most would be absolutely thrilled if you went to prison for a really long time. Even more would love it if you lost all your money and power. But what they would really love is if you and your companies would go away and stop interposing yourselves between them and the health care that they need, sucking their money into your maws like vampires. Speaking of which, we could add healthcare insurance executives, the Snidely Whiplashes that they are, to the Nazis and aliens and vampires and zombies that are now most of our movie villains. No one but their families would think that odd. People HATE you, and they hate you for good reason, because you have been responsible for the deaths of those they love. It is not just the companies, it is the people who run the companies who are doing evil!

The New Yorker has an article by Jia Tolentino, A Man Was Murdered in Cold Blood and You’re Laughing? (Dec 7, 2024). The title emphasizes the murder rather than all the evil that the victim and his ilk had perpetrated. But it tells us

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.

Tolentino also reports that a

2023 class-action lawsuit alleges that the NaviHealth algorithm [that Thompson brought into use at UnitedHealth] has a “known error rate” of ninety per cent [!!] and cites appalling patient stories,’ and ‘that Thompson was one of several UnitedHealth executives under investigation by the D.O.J. for accusations of insider trading.

Read it to see those stories. This was a truly bad man, and the real evil is that which he and his compatriots have done to the American people. Not everyone who does a bad thing is a bad person, but if you do enough bad things, and they are bad enough, often enough, then you are.

Thompson and his colleagues would probably say something like “this is how capitalism works, everyone tries to maximize profit”. That would be correct and it is an indictment of our whole unfettered capitalist system (in Noam Chomsky’s words, “gangster capitalism”). But the actions of health insurance company executive are seen as particularly egregious because their product is literally denying care to people and thus hurting or killing them. Per the New Yorker article

‘There had been prior threats against Thompson, his wife told NBC News, motivated, she said, by, “I don’t know, a lack of coverage? . . . I just know that he said there were some people that had been threatening him.”’

She doesn’t know?? These people live in a golden bubble; she thinks her husband is a good guy. You know, like Vito Corleone or Tony Soprano or El Chapo!

What is amazing is how unlikely the system is to change. While it did, significantly if not enough, under some Democratic administrations (Medicare under Johnson, ACA under Obama) it never went as far as eliminating for profit insurance companies and the drain they place on the dollars ostensibly spent on healthcare, or for that matter the entire economy; it is even less likely under the incoming Trump administration. Too many of the members of Congress are dependent on their contributions.

It is a little bit circular. If they had fewer dollars, if they had to be nonprofit, if they had to actually cover appropriate procedures as traditional Medicare does, they would have much less to contribute to and thus own our legislators.

Maybe then Congress would listen to, and do things that would benefit, us.