What We Want From Insurance

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AFFIRMING PSYCHIATRY

In the early morning hours of December 4, 2024, United Healthcare CEO Brian Thompson was gunned down on the streets of New York. Although the motives of the murderer are not certain, there are indications that he carried out a vigilante-style execution as an act of terror against the insurance company itself.¹ Unsurprisingly, his death sparked a national outpouring of opinions on the subject of health insurance and health care generally.

Much of that opinion was unsparing. Rather than sympathy toward Thompson or United, most immediate social media responses ranged from ironic jokes about denied coverage to outright celebration. The schadenfreude² and public rage³ both continued as United Group’s CEO (Andrew Witty) took to the editorial pages of The New York Times to defend his own. “Healthcare,” he opined, “is both intensely personal and very complicated, and the reasons behind coverage decisions are not well understood. We share some of the responsibility for that.”⁴

Readers do not appear to have been convinced. They called the essay “sanctimonious” and “self-serving.” “More gaslighting from an industry that has zero need to exist except to siphon profits from a non-discretionary sector,”⁴ said commentator “J M” to the tune of 4488 recommends.

While I personally do not agree with Witty’s opinion, I do have to admire his courage in speaking out just days after the assassination. And I can respect the courage of other commentators who went on record to speak up for insurance companies, paddling against the riptide of public emotion that was churning forth. For instance, the editorial board of the Wall Street Journal was sympathetic to insurance companies’ efforts to “control costs,” blaming government for “policies that distort the markets and force rationed care.”⁵ Matthew Yglesias, a nationally prominent blogger, has long maintained that the major problem with America’s health care system is that providers charge too much.⁶ Economist and blogger Noah Smith has been even more forthright²:

“I think the outpouring of schadenfreude at Thompson’s killing reflects some deep-seated popular misconceptions about the US health care industry. A whole lot of people—maybe most people—seem to regard health insurance companies as the main villains in the system, when in fact they’re only a very minor source of the problems. The insurance companies are simply hired to play the bad guy—and they’re paid a relatively modest fee for that service.”

Who is the real “bad guy” in our health care system? Well doctors and nurses, of course! Sure, doctors and nurses take good care of patients during the treatment process, but yet they charge “excessive prices.” According to Smith, doctors and nurses know that insurance is not going to pay a lot of those costs. The “smiling doctor” and the “gentle nurse” know full well that insurance is going to fight expensive procedures and drugs, and yet they never mention it. They offer all sorts of treatments knowing and apparently not caring that patients will get stuck with the bill. It is the providers that are the problem, you see. Insurance companies are just the poorly paid fall guy who cut costs so that doctors, nurses, and hospitals can play the ‘good guy.’

Rage Against the Insurance Companies

Not surprisingly, I as a physician have a different idea about all this. My idea is that the costs of treatment are only a secondary factor in the titanic rage against the insurance companies. I truly believe that while the expense of medical care is a serious problem for our system, the rage has to do with something else: The experience of being repeatedly and systematically hoodwinked. Hoodwinked? Exactly, at least according to 1 definition of the word: “To conceal one’s true motives from, especially by elaborately feigning good intentions so as to gain an end.”⁷ That is a precise description of what many of us experience with insurance companies. We feel repeatedly deceived by protestations of the best intentions followed by cold, calculating, and duplicitous treatment. And that is why so many New York Times readers responded so negatively to Witty’s bland pronouncements of goodwill on behalf of the insurance industry.

Although I have no hard evidence for this idea, I do have 20 years of experience with it in private practice. Whenever I treated individuals who paid for treatment directly out of pocket, I noticed the same pattern: They did not like the high price of treatment, but handled it calmly and kindly as long as they knew the costs in advance and could plan for them. On the other hand, individuals became absolutely livid if they had any sense of being deceived about the nature of our arrangement.

For instance, people who felt deceived about being charged for no-shows, or ill-informed about whether I was an in-network provider, would turn against me instantly and literally curse me to my face. Whenever individuals did not clearly understand the deal in advance, whenever they felt ambushed by hidden costs after committing themselves to treatment, learning of some new loophole or obligatory expense felt like a stab in the back. I have never seen anyone take kindly to a stab in the back.

And so, I submit that the rage against the insurance companies comes from a sense of being duped, not simply from high costs or limits of coverage. It is not the fact that insurance does not cover everything that makes people so angry. It is the impression that they pretend to cover so much, take your money for years in the form of high monthly premiums, and then in your hour of desperation and need, they refuse to pay up. Instead, they seem to find loopholes, make excuses, refuse to help, hide behind rules that no one can understand, and make it excessively difficult even to get a person on the telephone who can address the situation. It is not that insurance seems costly. It is that insurance seems duplicitous.

What We Want From Insurance

What do we want from insurance companies? We simply want a fair deal, a deal that we can understand in advance, a deal that they will faithfully honor.

What we want is an end to the befuddling obfuscation of a secret system that resembles Kafka’s The Trial more than something designed to facilitate health care.

What we want is an end to insurance feeling like a lotto card as you scratch off the next panel desperately hoping to win some actual coverage when you get sick.

What we want is an end to the infuriating game of ‘heads I win, tails you lose’ routinely played in the insurance business.

What we want is a straightforward transaction, not bland promises of ‘your health is in good hands with us,’ followed by callous disregard of our well-being.

What we want is an end to the systematic use of delays, knee-jerk denials, inefficiencies, time-wasting, and double-talk to numb us into passive acceptance of such ethical criminality.

Dearest Insurance Companies: Just offer us a deal that is straightforward and transparent, and live up to that deal. Then we can all decide if it is worth the cost, rather than going into apoplectic rage the next time that you manipulate the system against us—the very system that you design, administrate, and change at will. And then, perhaps, all the rest of us might really feel that we are on the same side, all trying our best to balance cost vs care, all trying to make the best of a very difficult situation. And then no one will have to be the “bad guy” in health care anymore.

Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

References

1. Kilgannon C, Baker M, Broadwater L, Hubler S. Suspect in C.E.O. killing withdrew from a life of privilege and promise. The New York Times. December 9, 2024. Accessed February 17, 2025. https://www.nytimes.com/2024/12/09/nyregion/united-healthcare-ceo-shooting-luigi-mangione.html

2. Smith N. Insurance companies aren’t the main villain of the U.S. health system. Noahpinion Substack. December 9, 2024. Accessed February 17, 2025. https://www.noahpinion.blog/p/insurance-companies-arent-the-main

3. Weaver C, Matthews AW, McGinty T. UnitedHealth’s army of doctors helped it collect billions more from Medicare. The Wall Street Journal. December 29, 2024. Accessed February 17, 2025. https://www.wsj.com/health/healthcare/unitedhealth-medicare-payments-doctors-c2a343db

4. Witty A. UnitedHealth Group C.E.O.: the health care system is flawed. Let’s fix it. The New York Times. December 13, 2025. Accessed February 17, 2025. https://www.nytimes.com/2024/12/13/opinion/united-health-care-brian-thompson-luigi-mangione.html

5. The Editorial Board. Is murdering healthcare CEO’s justified? The Wall Street Journal. December 6, 2024. Accessed February 17, 2025. https://www.wsj.com/opinion/health-insurance-unitedhealthcare-brian-thompson-murder-obamacare-medicare-taylor-lorenz-8f8ca0fb

6. Yglesias M. End the Medicare for All wars. Slow Boring Substack. December 12, 2024. Accessed February 17, 2025. https://www.slowboring.com/p/end-the-medicare-for-all-wars

7. The Learning Network. Word of the Day: hoodwink. April 7, 2014. Accessed February 17, 2025. https://archive.nytimes.com/learning.blogs.nytimes.com/2014/04/07/word-of-the-day-hoodwink/