The assassination of UnitedHealthcare CEO, Brian Thompson, in New York this week has sent shockwaves across the United States.
The incident has also led to an outpouring of anger from Americans against their country's healthcare system.
Washington Correspondent Sean Whelan looks at the different issues US healthcare has.
Whenever I feel I need to see a doctor in this country, I am gripped by a reverie – a waking dream in which I see a palm fringed marina full of beautiful yachts beneath a beautiful clear blue sky. Maybe it is a kind of placebo effect, because about half the time I put off contacting my "provider" - because it's their yacht I am thinking of.
Everybody knows the American health system is rotten. And it is not just foreigners talking from abroad. Everybody tells you so as soon as you arrive here, especially when you sign up for health insurance. Maybe it's their way of easing you past the shocking cost.
Then there are the healthcare professionals – all the ones I have seen here over the past three years either tell me it is a bad system or agree with me when I say it. Again, maybe it's their way of getting past a narky customer. Or maybe it's what they really think.
As for the American public, fear and loathing pretty much sums up their attitude to their health system. They loath the rapacious nature of the all-devouring health beast and its high-cost-everything approach: and they fear losing their employer-provided health insurance.
For without insurance, the hapless individual is thrown to the wolves: either come up with the cash yourself, or suffer, or die. And the cost of insurance? It's not uncommon for people to spend more on their monthly health insurance bill than on their mortgage.
Its a rotten system, many people would love to change it, and regard themselves or their loved ones as its victims.
But do they hate it enough to kill in cold blood to make their point?
This is the question being asked in the wake of the assassination of Brian Thompson, the CEO of Americas biggest health insurer, on Wednesday morning. He was gunned down outside the midtown Manhattan hotel he was about to enter to address an investor conference, an important event for one of America’s biggest companies, a company valued on the stock market at $560 billion, and with 140,000 employees.
Despite this – and a fairly persistent level of threats towards the company and its executives from customers who consider themselves as victims, activist groups seeking healthcare reform and others seeking broader changes – he had no security detail with him (though it's reported that he has had one previously).
His executive pay was $10 million a year, mostly in the form of bonus and share options: his basic was a million a year. A big pay packet, but not outrageous for very big American companies, especially from one that made $16 billion in profit last year (Elon Musk is fighting a court battle to retain a $50 billion compensation package from Tesla, the loss-making electric vehicle company he founded).
Executive protection is a pretty big business – lots of ex-military and ex-law enforcement go into the trade. Oil and gas are a big customer, as are other businesses that attract controversy. And health insurance definitely attracts controversy.
In Ireland we traditionally are told not to speak ill of the dead. That old social constraint does not apply to social media, which has seen an outpouring of hate for the medical insurance industry in general, and Mr Thompson’s company in particular, in the hours and days since his murder.
The most extreme have accused Mr Thompson and UnitedHealthcare of committing mass murder by denying health insurance cover or claims. A coverage refusal can be catastrophic for individuals. Some have claimed that United was pioneering an AI system that would process coverage claims much faster than humans, but which they allege was producing a much higher rate of claim denial or coverage refusal.
Such claims are now part of a police murder investigation that is looking for a motive for the slaying of a business executive who was highly regarded in his own industry. And that in turn is shining a spotlight on a perennial, and seemingly intractable problem in America – the incredibly high cost of medical care.
Even with health insurance, the costs of illness to Americans are enormous – often unbearable in a country where 37% the population cannot come up with $400 in cash to cope with an emergency expense, according to the Federal Reserve.
Another survey for financial comparison site Bankrate claims 63% of Americans would be financially derailed by an emergency bill of $1,000. That could be anything from a damaged automobile part, or part of a medical bill. Because insurance will not cover everything – there are excesses, co-pays, deductibles.
Those paid to defend the industry say you have a free choice of doctors and "providers". This is true but they have a free choice of who to pay or not pay - you need to pick an "in-network" provider to get the most coverage. It is a veritable minefield to be negotiated, a simple test requiring hours of phone calls, web searches and hanging around to make sure the bill is the smallest it can be.
Then there are things they simply will not cover and will not pay for. You may think you are ok because you have health insurance, but when the going gets tough, you can suddenly find you are not covered for the very thing you need. Or you wake up in the recovery room and find a six-digit bill awaits you because of circumstances and the complexities of the medical insurance system. Or because an insurer simply said "No".
The killing of Mr Thompson prompted an eruption of posts on social media platforms from people who had been denied coverage for claims by UnitedHealthcare and other insurance companies. Tales of Medical Bankruptcy, unnecessary death, emotional and physical suffering.
And just pure hate. "My thoughts and prayers are out of network", "My empathy hasn’t met its deductible", "prior authorization is needed for thoughts and prayers", are just some of the more printable comments. More than a few expressed sympathy for the gunman. But there is more to this than the quotidian nastiness of puerile posters on X.
The New York Times quoted a poster on TikTok who commented on the Thompson assassination: "I pay $1,300 a month for health insurance with an $8,000 deductible. ($23,000 yearly). When I finally reached that deductible, they denied my claims. He was making a million dollars a month."
The paper also quoted Author Joyce Carol Oates in another social media post: the outpouring of negativity "is better described as cries from the heart of a deeply wounded and betrayed country; hundreds of thousands of Americans shamelessly exploited by health-care insurers reacting to a single act of violence against just one of their multimillionaire executives."
Clearly the assassination, regardless of whether it ultimately has anything to do with Mr Thompson's work as a health insurance executive, has touched a raw nerve in America. The extraordinary cost of medicine in America.
It is why so many people here don’t go to a doctor, putting up instead with chronic conditions, living restricted lives, underperforming their potential.
Not only is this system bad for individuals, but it is also bad for the economy. Some very pro-business commentators here argue the fear of losing an employer provided insurance cover stops people from becoming entrepreneurs, starting their own business and helping to grow the economy faster.
For those who are ordinary employees, redundancy can be devastating because it means the loss of health insurance cover for them and their family. A factory closure, a sunset industry, the fear of being stranded without a job is made infinitely worse by the fear of getting sick or having an accident. Or just a toothache.
It makes the social process of transitioning form one job to another much more difficult, complex and stressful (and stress often leads to chronic medical conditions that need treatment). At a time of rapid technological shifts that are already discomforting large swaths of Western populations, the added stress of the dysfunctional American health system makes an already stressed population worse.
A manager from a European company told me two years ago about doing a post-Covid tour of some of the offices he directs. One was in Portugal, the other in North Carolina. Both did the same thing for the company, doing the same work on the same project, just in different time zones.
But he also noticed a big difference in the staff: in Portugal, with its single payer medical system and social security net, the staff were happier, more relaxed, more collaborative and had higher output (though they worked shorter hours).
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The US staff he described as needy, backstabbing, competitive with each other, fearful of losing their job and benefits package, so determined that someone else on the team would go under the bus before them. This consumed so much time and emotional effort that they were not very productive, despite the long hours culture. They also demanded higher pay than their European counterparts.
To entertain the manager, the Portuguese office brought him out to a courtyard where the neighbours (helped out by a corporate engagement programme) had laid on grilled food, wine and music.
In the US, he ate from a vending machine, and the corporate entertainment was to be brought to a shooting range to blast off a lot of rounds on AR-15s. He was sure that healthcare and social security had something to do with the huge difference in workplace culture. (The big downside with Portugal was the housing shortage, driving rents sky high).
But if the system is so bad, why not change it? There have been efforts – the Affordable Care Act, popularly known as Obamacare – has been a big improvement in increasing the number of insured individuals. Republican politicians leaned on Donald Trump to tone down his message of scrapping Obamacare during the past election cycle, because they know it was a vote loser for the party.
But it's still a super high-cost system. The big impediment to change is the amount of money at stake that incentivises those in the system to hold what they have and can be deployed against outsiders to stop them upsetting the status quo.
It is quite striking the amount of pharmaceutical medicine advertising that goes on here, especially on the cable news channels like CNN, MSNBC and Fox News. Every ad break is stuffed – and sometimes exclusively filled – with ads from drug companies, promoting prescription medicines. Ozempic, diabetes drugs, erectile disfunction drugs, HIV drugs – the come in seasonal waves. I for one am heartily sick of ads for Plaque Psoriasis drugs on breakfast TV.
Such advertising is banned in Europe, so it comes as a shock to see it. It also adds heavily to the price of the medicines to consumers, so no surprise they are the highest on earth here, as the advertising overhead has to be loaded onto the price the end user pays.
Again, affording them depends on the health insurance programme you have (or don’t have).
For years the OECD (Organisation for Economic Co-operation and Development) has highlighted the super-high cost of the American healthcare system. In its latest "Health at a glance" publication (always worth a look), the club of rich countries once again highlights the data showing the US spends 16.6% of GDP on healthcare, way above the 9.2% average for OEC (Observatory of Economic Complexity) countries.
In cash terms – in purchasing power parity US dollars, to make it comparable – the US spends $12,555 per head of population on health: the OECD average is $4,986. In Ireland it’s $6,047.
But it does not get far superior health outcomes for such lavish outlay. Indeed, on the most important health indicator of all – life expectancy – the US is a laggard, with an average life expectancy of 76.4 years, compared with an OECD average of 80.3 years. In Ireland its 82.4 years.
On preventable illness, the US again does significantly worse than average – 238 cases per 100,000, compared with an average of 158 (and 109 in Ireland, though that is pre-Covid data).
Pharmaceutical costs in the US work out at an average per capita of $1,432, compared with an average of $614 for 33 OECD countries (it is $625 for Ireland and $466 in the UK).
The US system is incredibly costly, incredibly cumbersome, incredibly bureaucratic – and, almost incredibly, does not deliver particularly good outcomes for American consumers.
Yes, some people here can get absolutely the best medical care available on the planet - they can get operations nobody else can get, drugs nobody else can get, service few on earth can get. But that is not the experience of all – not by a long way.
The average health outcomes tell the real story of the mismatch between spending and results that leaves Americans anxious, fretful, stressed, insecure, sometimes damaged, and as it seems, occasionally murderous.
There are many, many wonderful things about America. Its healthcare system is not one of them.
