The Private Fire Brigade

Ordinary Americans are afraid of being unable to get the procedures they need or bankrupting themselves by paying for medical emergencies. They’re so terrified of this prospect, in fact, that they’re willing to spend decades paying into the functional equivalent of an extortion racket for the theoretical promise of services that, in any normal country, would just be provided to everyone as a public good, free at the point of service.

It’s the modern equivalent of the private fire brigade operated by Marcus Licinius Crassus in ancient Rome. Crassus would go to a home that was burning down, trailed by slaves with buckets of water, and offer to put out the blaze — if the owners first agreed to sell their home to Crassus at a fraction of its value. Like the health insurance companies today, this was a business model premised on the insight that people will agree to anything when they’re afraid of losing everything.

Many people stay in jobs they hate, or even bad marriages, for fear of losing employer or spousal health insurance. People who dream of taking time off to write a novel or travel or risk going into business for themselves often hold back for the same reason. And when the time does come to use the service they’ve been paying into for all these years, the companies’ profit incentives give them every reason to search for excuses to deny claims. “Deny” and “delay” are standard insurance industry tactics. It’s common for people already physically and emotionally exhausted by caring for dying relatives to have to navigate a bureaucratic nightmare to get potentially life-saving procedures covered. Insurers overrule doctors all the time.

If Thompson had just been a typical health insurance CEO, he would have had plenty of deaths and a great deal of misery to answer for. But UnitedHealthcare was a particularly egregious offender. According to the Boston Globe, the company “dismissed about one in every three claims in 2023 — the most of any major insurer” and “twice the industry average of 16 percent.” A rate like that is great news for UnitedHealthcare shareholders. But it also leaves a trail of corpses in its wake.

Survival of the Richest

In an article for the Atlantic, Graeme Wood wags his finger at the “many people” who seem eager to turn Luigi Mangione “into a folk hero, an avenger who had interrupted a predatory capitalist in mid-mustache-twirl.” Without mentioning UnitedHealthcare’s sky-high denial rate, Wood scoffs at those who would accuse Thompson of “mass killing — as if his company hunted its customers and gunned them down in the streets.”

It’s certainly true that the people who die because of UnitedHealthcare’s business model aren’t “gunned down in the streets.” They’re often in hospital beds while people who love them spend all day on the phone with the insurance company.

This reality is conspicuously absent from Wood’s account. Without sullying his narrative by quoting any of the patients, doctors, or ER nurses who’ve spoken out about their outrage at the system in the weeks since Thompson was killed, Wood admonishes all the “otherwise smart people” who “seem not to realize that health care involves trade-offs” and “that countries without private insurance tend to ration it.”

If “rationing” means parceling out in a stingy and insufficient way, then this is nonsense. The statistics are crystal clear. Otherwise comparable nations like Canada and the UK with socialized systems have far lower rates of “mortality amenable to health care” than the United States. (That’s statistician speak for “people who died even though they could have been saved by timely medical intervention.”) If Wood merely means to point out that no health care system has unlimited resources, such that all systems, public or private, have to “ration” care, then it’s a trivial point — and insulting to the intelligence of the Atlantic’s readers.

A reform like the single-payer “Medicare for All” system would mean that every single human being in our society would have a rock-solid guarantee of basic health care, free at the point of service, with no obstacle course of bureaucratic nonsense in between patients and their care. Would it have unlimited resources? Of course not. But the blindingly obvious moral and practical point that Wood obscures is that considerations of shareholder profits would not be part of such determinations. When genuine limits are reached and hard decisions have to be made, the most barbaric way of navigating these trade-offs is by rationing care on the basis of income — letting some people live and others die depending on who can afford better insurance or simply swallow the out-of-pocket costs.

Wood finds it incomprehensible that anyone would see Thompson as “predatory” or callously indifferent to the victims of his industry (“mid-mustache twirl”). Writing in the New York Times, but in a way that’s indistinguishable from what he might say in a corporate press release, UnitedHealth Group CEO Andrew Witty paints a warm picture of his fallen colleague. (UnitedHealth Group is the larger company, and UnitedHealthcare is its insurance branch.) He writes:

B.T., as we knew him, worked farm jobs as a kid and fished at a gravel pit with his brother. He never forgot where he came from. . . .

When a colleague proposed a new idea to Brian, he would always ask, “Would you want this for your own family?” If not, end of discussion.

If this is true, it’s strange that Thompson approved the use of an AI system, empowered to overrule human decisions on coverage, that had a brain-melting 90 percent error rate. Perhaps whoever B. T. was throwing around ideas with assured him that they would want their family to be denied care based on the determinations of a mindless algorithm with an eye-popping error rate. Or perhaps they just reminded him that it would be really good for UnitedHealthcare’s quarterly profit projections.

Ranking “Working-Class Heroes”

Witty grants, in that op-ed, that America’s health care system is “not perfect,” that it “does not work as well as it should,” and that he “understand[s] people’s frustrations with it.” But apparently it’s no one’s fault.

No one would design a system like the one we have. And no one did. It’s a patchwork built over decades. Our mission is to help make it work better.

Even apart from the fact that nothing but their own insatiable lust for profits made them authorize AI to overrule doctors, the level of shamelessness on display here is off the charts. No one, you see, designed this system. It just sort of happened. In reality, of course, the political power of companies like UnitedHealth Group is precisely what stops the system from being replaced with a better one like Medicare for All. Witty’s company lavishes millions on lobbying and political donations to make sure no one touches its murderous business model. And then Witty himself turns around and writes for the New York Times that, gosh, we all just found ourselves in a system like this, what can you do?

Not to be outdone in brazenness, Bret Stephens wrote an op-ed for the New York Times calling Brian Thompson — a man under investigation for federal antitrust violations, and who was, when he was assassinated, being sued by multiple pension funds for offloading $117 million in company stock on them before the antitrust probe went public — as a “working-class hero.” He writes:

Thompson’s life may have been cut brutally short, but it will remain a model for how a talented and determined man from humble roots can still rise to the top of corporate life without the benefit of rich parents and an Ivy League degree.

Stephens simply can’t stretch his imagination far enough to imagine any goal for exploited working-class people other than the best and brightest among them becoming upwardly mobile and graduating to become exploiters themselves. He simply assumes a worldview that, as I’ve put it elsewhere, cares infinitely more about “shattering glass ceilings” than “raising the floor of material security for everyone,” by, for example, making health care a universal social right.

Like Wood, Stephens milks the contrast between Thompson’s “humble roots” and the fact that Mangione came from a privileged background. But the latter just shows that America’s health care system is so dystopian that you don’t have to be poor to spot the problem, or maybe even experience it yourself. While details of Mangione’s personal exposure to the injustices of the system are still being revealed, it’s clear that he had a debilitating back injury and a frustrating journey through private health care. He can’t be blamed for being observant.

The problem with what Mangione did isn’t that a privileged person like him should have loved the parasitical health insurance companies. It’s that, even beyond a purely moral objection to murder, assassinations are a political dead end. No powerful industry has ever been defeated that way.

Killing any particular CEO will just lead to someone equally bad taking his place. We need to build a mass movement of the organized working class, in workplaces and in the political sphere, to defeat the Brian Thompsons of the world and strip them of their power. That’s a lot harder, but it’s the only way we can ever win.