The murder of United Healthcare CEO Brian Thompson horrified me. I did not know him. I thought first about his wife and young sons and the shock and grief they — and his colleagues — must feel. I then realized that they must now live in fear for their lives.
I was also not at all surprised by those who saw this differently. I have written about greed in health care. Someone I know smiled for a moment when I shared the news. Some social media posts celebrated, while others condemned the murder but understood the perceived motive: to strike in anger at someone representing a system that has failed them. (At least one did it through song.) Thompson has become not a person but a personification of a broken system.
What has led us to this point?
First: so much suffering. The vast majority of Americans report that health care is unaffordable or that they fear bankruptcy if they need care. When they try, they can’t find a primary care physician, can’t get a procedure without the hassles of preauthorization, and may not be able to pay for their prescriptions. Everyone I know who came to work in health care did so because they wanted to help others — and yes, even at United. And many now experience the moral injury that comes from being unable to do so, including those who work in health insurance.
We must also recognize the broader harms caused by rising health care costs. We spend twice as much as our peer nations and get worse results. These arguably avoidable costs make American businesses less competitive; contribute to higher local, state, and federal taxes; and squeeze out government investments in education, housing, and the other vital conditions required to create thriving communities and a productive workforce. It is no surprise that Warren Buffet has referred to health care costs as the “tapeworm of American economic competitiveness.”
No wonder people are angry. And because health insurance has become the face of both the rising premiums and the intrusive cost-containment efforts that are largely delegated to them, they have become the primary target of that anger. But it’s not just insurers. Hospitals — whether for-profit or nonprofit — are increasingly understood to be part of the problem, perhaps because of the high bills that drive many into debt and the pervasive and well deserved news coverage that results.
These are all symptoms of a broken system.
Two underlying causes deserve attention.
First, health care, like so much of the American economy, is becoming financialized, a system focused on making money. Private equity is the canary in the coal mine of for-profit behavior, having moved aggressively into health care. Most large health insurers, such as United, are for-profit, but the degree to which they and other firms have narrowed their focus to their stock values (rather than producing good products and services) has increased dramatically in recent decades. More than a third of hospitals are for-profit, but many not-for-profit hospitals still focus on maximizing their revenues and margins, in part because their chief financial officers have to worry about their bond ratings. (Perhaps also because they have boards filled with bankers rather than health care professionals and patients.) And the easiest way to increase your revenues is by becoming a monopoly. Now, in health care, most markets are too concentrated to support meaningful competition: this is the case for 90% of hospital markets, 65% of physician specialist markets, and 57% of insurer markets. I am a firm believer in markets, but market failure is now pervasive in health care.
Second, a related problem: Special interests show up, the rest of us don’t. This is formally known as the “collective action problem.” More colloquially: We let it happen. By “we,” I don’t mean patients or the small businesses struggling to provide insurance for their employees. I mean the large organizations (businesses, universities) that have tried to cut a better deal for themselves while failing to see the larger system. I mean those of us working in health policy who have watched spending rise inexorably on our watch without questioning our assumptions. I mean myself. I was not paying attention while health care premiums in Vermont skyrocketed.
I am also convinced that we can do better.
In a recent commentary in the New England Journal of Medicine, colleagues and I argue that states are well-positioned to lead efforts to slow spending growth. We argue that health care is like a balloon: As policymakers push on spending growth in one area, those targeted can easily find other ways to increase their revenues. (It’s particularly easy if you are a monopoly). To push back effectively we need regulatory agencies with a clear charge: ensuring that everyone can receive affordable, high-quality care. Those agencies need to set spending growth targets and have the data and analytic capacity to identify the drivers of wasteful spending or avoidable care. And they need the authority and policy tools that can enable them to ensure that spending targets are achieved, such as provider rate setting, insurance affordability standards, and enforceable improvement plans. These are tools that can, if effectively implemented, make it more likely that targets are achieved.
To succeed, however, all of us who care about the future of health care — business and health care leaders, legislators and citizens — will need to come together across the many ways we are divided. We need to see ourselves as stewards of our communities and put in place the regulatory agencies that can ensure that serving the public good is as important as financial solvency. And when providers, insurance companies, and regulators disagree, as is the case at this moment here in Vermont, we need to find ways to sit together and constructively solve the problems we face.
Brian Thompson was an advocate for universal coverage through private insurance. I have argued here and elsewhere that better policy, including effective regulation, should make that possible. Perhaps, if we can begin to make affordable, accessible, high-quality health care a reality for everyone, fewer people will feel excluded, disrespected, uncared for — and angry.
Elliott Fisher, M.D., M.P.H., is professor of health policy, medicine, and community and family medicine at the Dartmouth Institute and the Geisel School of Medicine.