Who Wants to Be On the Death Panel?

PR thoughts on the murder of an insurance man

Two weeks ago, Brian Thompson, CEO of big health insurer United Healthcare, was gunned down in New York. This created an epic amount of Discourse on social media, aggravated by the mysterious nature of the killer and his temporary escape. This week, a suspect named Luigi Mangione was arrested. He turned out to be a bit of a snack, which is causing weird undulations in the fabric of the media continuum.

The trajectory of the social discourse was amazing. Immediately after the news broke, there was a wave of gleeful social media posts. That was followed by a second wave scolding those making jokes and celebrating Mr. Thompson’s death. Completing the ouroboros, there was then a wave scolding the scolds for not acknowledging the depth of popular hatred of big health insurers.

If a prominent executive in your industry is gunned down on a sidewalk and the public response is party-poppers and dancing in the streets, you should ask yourself some hard questions!

It’s easy to say, “everyone hates health insurers.” But why? And why so much?

The American health industrial complex is mediocre at health outcomes, but world-class at enraging people at scale. I had a month off between jobs recently, which was great, but I had to ritually incinerate $5,000 on the altar of COBRA. I have a teenage son and we both ride bikes and being uninsured for even a minute in this country is like buying a reverse lottery ticket where the prize is losing your house.

Then, because new company = new plan, I had to switch insurers after 12 years. This means finding a new doctor and learning a new set of weird idiosyncrasies that could prevent access to care. I had got used to a relatively predictable HMO model, where the insurer and provider are integrated. Now I have to play “is it in network?” roulette, which is like Russian roulette if the pistol fired an enormous bill into your bank account. And my problems are trivial! People with actual health issues live in a state of permanent stress about this stuff.

There are better ways. Last August, when we were in Singapore, my father-in-law got Covid and had to be admitted to hospital. My son and I took him to a government hospital, where he was seen and admitted promptly. He was there for five days, during which we got abundant updates on his condition. His bill was USD$3,700, but his out-of-pocket after subsidies was $330, in a city that’s considered one of the most expensive in the world on every other metric! In the U.S., $3,700 pays for just over a day of inpatient care on average. Fourteen years ago, $330 got my son a ten minute pediatric consult for diarrhea at Palo Alto Medical Foundation during what I now remember as “the year norovirus ate Christmas.”

Healthcare is a limited resource and there will always be rationing mechanisms, often several operating in combination. The simplest one is money. If you can pay, you can get care. Another is gatekeepers, like the GP screening you before sending you to a specialist. Yet another is wait times, like six months to get an appointment for your bunions. Rationing sucks, and people hate all of these! In the UK and Canada, national health service wait times are a huge political issue.

Healthcare is also a giant industry with lots of interest groups, and societies have painful debates about how to structure and balance the revenue and rationing mechanisms of their health systems. That’s what the “death panel” attacks on Barack Obama’s Affordable Care Act were about, back in 2009. Republicans invoked the specter of faceless “government bureaucrats” deciding who gets care. But, at the risk of oversimplifying, there is always a death panel somewhere in the system unless you can buy your way out of it. “Death Panel” is just emotionally charged language for “rationing mechanism.”

A key question is, what incentive system is the death panel operating in? Or, more accurately, what incentive system does the public perceive the death panel to be operating in? It is a peculiarity of American hyper-capitalism that a for-profit death panel can be presented as superior to one operated in the service of some non-financial metric. Personally, I don’t wish to hear that my death, while regrettable, will help my insurer to meet its quarterly financial targets.

The perceived motivation of rationing is important. I’m a bit of a hypochondriac, and I sometimes go see my GP about some minor issue that I am convinced is killing me. When I went to him a year ago about a new spot on my face that I just knew was skin cancer, he wasn’t alarmed and didn’t refer me to the dermatologist. It was fine. To paraphrase the great Ellen Ripley, I didn’t think he was fucking me over for a percentage. (The spot went away.)

But the idea that people in distress are denied sometimes lifesaving care so that big insurance companies can be more profitable feels deeply unfair. Another artifact of the American system is the giant, surprise bill. This is the insurance company retroactively applying financial rationing, often with a coldly bureaucratic explanation. When his happens to someone who has been faithfully paying premiums, it feels like betrayal. If you think it’s being done for nakedly financial reasons, you’ll be ready to put on the Guy Fawkes mask and burn it all down.

Just off to see the insurance man, Evey.

Corporate PR is often asymmetric. It is hard to counter deeply personal tales of suffering with corporate platitudes. And the American health insurance industry generates an endless supply of brutally tear-jerking collisions of human frailty with granite cliffs of bureaucratic denial. Every Gofundme is an indictment. We easily project ourselves into these stories. Deep down, we all know we’re on a one-way journey toward age and infirmity. Or we might just draw the short straw in the form of an accident or illness.

A couple of days ago, the CEO of United Health Group, United Healthcare’s parent company, published an opinion piece in the New York Times. In it, he decried the anger directed at his group’s employees and noted that the American health system is a flawed patchwork full of people trying to do their best. As I read it, this is what I was thinking:

It was a perfectly reasonable bit of public relations, and he was explicitly trying to address the asymmetry problem by putting a human face on his company:

“The people of UnitedHealth Group are nurses, doctors, patient and client advocates, technologists and more. They all come to work each day to provide critical health services for millions of Americans in need.”

He also wrote:

“We know the health system does not work as well as it should, and we understand people’s frustrations with it. No one would design a system like the one we have. And no one did. It’s a patchwork built over decades.”

And he’s right! The American health system is complicated, inefficient and bureaucratic, and full of good people trying their best. It subsumes a thousand questionable motives along with many good ones. But giant insurers aren’t passive actors in the system. They’ve actively lobbied and shaped the system in which they operate.

And I am not sure there is a PR solution for UnitedHealth Group in the context of America’s current healthcare system. There are times in PR when the question stops being, “how do we stop people from being angry?” and becomes “where do we want the anger directed?” The anger is water in a balloon. You can squeeze it from place to place, but it’s always there. For all the other players in the system—hospitals, doctors, pharmacy benefit mangers, pharma companies—it seems useful to export as much reputation risk and public anger as possible onto the insurers. They can be the industry’s “pain sponge.” As the most visible part of the rationing mechanism, the conveners of the death panels, they’re well set up for it.

The outpouring of public glee at the death of Mr. Thompson made me uncomfortable. I resisted the temptation to tell random people on the Internet what they should or should not post because that seems like bailing an ocean of gasoline with a flaming teaspoon. But a problem with “death to [your villain here]!” as an operating principle is that, historically speaking, it tends to escape the constraints of virtue. Also, to be self-centered, when the revolution comes, corporate PR people are going up against the wall, right next to the lawyers and insurance execs.

Most posters are just expressing their anger at a system everyone knows is broken, and don’t really mean to advocate for extrajudicial executions of insurance executives. But one population-level effect of social media is to create or bend permission structures, sometimes for bad things. And, these days especially, I would be careful about engaging with anything that might expand the permission structure for violence, even against insurance CEOs. There are already quite enough death panels.

Some other reading, mostly from the first week (may require subscriptions):

• New York Times: Torrent of Hate for Health Insurance Industry Follows C.E.O.’s Killing

• New York Times: The Rage and Glee That Followed a C.E.O.’s Killing Should Ring All Alarms

• New York Times: Some on Social Media See Suspect in C.E.O. Killing as a Folk Hero

• Bloomberg: United Healthcare Shooting Dredges Up Hatred for Health Insurers

• Charles Arthur (technology journalist): A World of Haters

• Washington Post: Fearful of crime, the tech elite transform their homes into military bunkers

• The New Yorker: A Man Was Murdered in Cold Blood and You’re Laughing?