US health reform is tough to pass. Can the brazen killing of a CEO change that?

Rage, frustration and bitterness – all were on display in social media comments following the fatal shooting of the UnitedHealthcare CEO, Brian Thompson.

Despite being brazenly murdered in midtown Manhattan just before the company’s annual investor conference, leaving behind a widow and two sons, many Americans struggled to find sympathy for a man they viewed as complicit in denying or deferring what they saw as needed care – rage that one prominent policy expert can understand.

“Dissatisfaction – in the sense that the system isn’t working, it’s broken – is at an all-time high,” said Ezekiel Emanuel, one of the architects of the law better known as Obamacare, and a professor of health policy at the University of Pennsylvania’s Perelman School of Medicine.

“Everyone hates the system now more than when we passed the Affordable Care Act.”

Police said the suspect they arrested this week, 26-year-old Luigi Mangione, was also in possession of a kind of manifesto – a “handwritten three page document” that professed “ill-will toward corporate America” – including references to healthcare.

Retirees protesting outside city hall in New York on 12 October 2022. Photograph: Shawn Inglima/New York Daily News via Getty Images

Last week, police said shell casings recovered at the scene were scrawled with the words “deny”, “depose” and “defend” – words many Americans associate with health insurance denials – and recovered a backpack potentially connected to the shooting filled with Monopoly money.

The incident has caused alarm for researchers of violence, who said the killing represents an extension of political violence into the commercial realm, and has shaken corporate executives. UnitedHealth Group, for instance, pledged to harden its campus, the CEO told employees.

“No matter how deep our grievances or how righteous our anger may feel, violence has no place in our society,” wrote Wendell Potter, a former health insurance executive turned advocate for reform, in his weekly newsletter.

Still, he added, “this corporate assassination is a symptom of a nation buckling under the weight of systemic dysfunction”.

Passed in 2010, Obamacare was arguably the most ambitious health reform law in a generation. The ACA prevented insurers from discriminating against sick people, brought health insurance to millions more people, and held the total cost of healthcare (usually expressed as a percentage of gross domestic product) relatively stable.

“This really is a paradox,” said Emanuel, going through a list of progressive changes that have taken root since the ACA went into effect. “That doesn’t mean the system is working well. That’s hardly how we experience it.”

Instead, he said, consumer experience of the law is often typified by “prior authorization, inability to find a doctor, shortages of common medications like amoxicillin and asthma stuff people need”, and the “burnout level” of doctors and nurses still typify the American health system, said Emanuel.

The health industry has consolidated heavily over the decade, leading to higher prices and even more powerful special interests that lawmakers would have to face for any reform – no matter how incremental.

Thompson worked as the head of the insurance division at UnitedHealth Group. The corporation is now ranked as the fourth-largest US company, behind only Walmart, Amazon and Apple, according to Fortune – a fact mentioned by Mangione himself in his so-called “manifesto”.

UnitedHealth Group is also ranked as the eighth-largest company on Fortune’s global index – ahead of ExxonMobil, Shell, Google parent company Alphabet, Volkswagen, GM and JPMorgan Chase. That’s up from 10th globally in 2023 and way up from 63rd in 2012, one year after the passage of Obamacare.

Other healthcare giants also rank in the top companies in the US and world: CVS, a pharmacy that now also owns the health insurance company Aetna and pharmacy benefit manager Caremark, is the sixth on the US list.

“No entity in history, certainly not a company traded on the New York Stock Exchange where profit margins are all that matter – has been in a position to deny or delay essential health care on a scale that UnitedHealth does day in and day out,” Potter wrote this week.

With partisan gridlock and entrenched special interests, such as health insurers, now more powerful than ever, he added, itwas difficult to know how to move forward.

“One of our problems at the moment is it’s not clear what the comprehensive reform of the American health system would be,” said Emanuel. “People have not figured that out,” he adding, saying that it was not the fault of the public but “policy experts like me”.

In some cases, overwhelmingly popular policies seem to go nowhere – like the Vermont senator Bernie Sanders’ proposal to add vision, dental and hearing benefits to Medicare, the public health insurance program for older adults. Polls suggest that the policy enjoys support from 84% of the public. But it has not advanced significantly in part, Sanders argues, because of industry opposition.

“I don’t have to tell you that the insurance companies, the drug companies have zillions of lobbyists here in Washington,” Sanders told the Guardian in May. He later added: “The function of our healthcare system is not to provide high-quality care, but to make huge profits for drug companies and insurance companies.”

The ACA required the federal government to track insurance company denial rates, data that was supposed to be shared with state insurance commissioners.

Yet, “to date, such information-gathering has been haphazard and limited to a small subset of plans, and the data isn’t audited to ensure it is complete”, an editorial from KFF Health News reported in 2023.

Now, there is little data to support patients’ suspicions that they are being denied at higher rates, an issue that has only become more urgent as insurers employ artificial intelligence to deny claims in batches.

In some cases, issues have persisted despite legal reform. California enacted one of the first laws against “ghost networks” – inaccurate and misleading insurance networks that make it appear there are more providers than actually participate in the network. In spite of the new law, only one insurance plan has been fined $7,500, according to reporting by ProPublica.

“People feel like the system is not working for them, and in some ways it reminds you of the experience of the Biden team, [when] Bidenomics is working,” said Emanuel. Big-picture data shows things are moving in the right direction, he added, but “the American public is saying: ‘We’re not buying any of it’”.