"Frankly, these parasites had it coming."
On Luigi Mangione's cheerleaders and the state of U.S. health insurance
Luigi Mangione appeared calm as he exited a Pennsylvania courthouse yesterday and entered NYPD custody. A group of supporters had gathered carrying signs reading “Free Luigi!” and “Murder for Profit is Terrorism.” The apparent cold-blooded assassin of insurance executive Brian Thompson has become something of a folk hero to aggrieved patients across the political spectrum.
One reason is obvious: people with severe illnesses are often denied treatment by insurance companies. In a 2023 report, the Kaiser Family Foundation found that major insurers on Obamacare plans denied up to 49% of 2021 claims. As Betsy McCaughey noted in the New York Post this week, delays or denials at times yield swift and fatal consequences.
McCaughey cites a story told by oncologist Dr. Debra Patt in a March 2023 interview with the American Medical Association. Patt had prescribed a promising new treatment for a 40-year-old patient with rapidly spreading metastatic breast cancer, but the patient’s insurer denied the treatment. Patt appealed—the insurer denied again, then told Patt that it could take up to six weeks for a peer-to-peer review process to either approve or conclusively deny the treatment. All the while, the patient’s condition was worsening.
Patt informed the patient that she did not think they could safely wait any longer to begin some form of treatment, even if it was not the best available. She explained that the evidence suggested that her initially prescribed treatment was “twice as good” as the chemotherapy the patient went on to take. She died within a few months, a fact which Patt clearly struggles with. As she told the interviewer,
It's terrible. [Utilization management] is for the purpose of managing cost, and I understand that. But when insured patients that pay for their insurance can't get the care that they need and it leads to an adverse outcome, it’s really challenging. I would just go for a very long time, lead a lot of studies in breast cancer to be able to do what I do really well. And when I know—and sometimes we lose patients because cancer is terrible and maybe we don't have other things to offer—but when we do have the best treatments to offer and cannot get it to the patients we serve who pay for their insurance, it's really frustrating and demoralizing as a physician.
In other words, Patt, who holds both MD and PhD degrees, spends a great deal of her time researching treatments for seriously ill patients before arriving at clinical decisions. When she prescribes treatments, she believes them to be the very best available and that her insured patients ought to be able to access them. At the very least, her opinion as a physician ought not be second-guessed by insurance representatives with no relevant medical training.
Patt also objects to the “peer-to-peer” process instituted by insurance companies as part of the appeals process, which subjects her clinical decision to the review of other physicians. They might not be oncologists, she explained, and certainly will not be as informed about the particular patient. Doctors are increasingly instructed to obtain prior authorizations for a wide range of treatments and medications; as the AMA warns, an ob/gyn could veto a neurosurgeon’s recommendation. And the process can result in fatal delays.
Stories like this have proliferated over the last decade or so, leading many to justify or even celebrate Luigi Mangione’s alleged brutal act. At the time of his arrest at a McDonald’s in Altoona, Pennsylvania, Mangione was reportedly carrying a handwritten “manifesto” proclaiming that, “frankly, these parasites had it coming.” Public figures—from U.S. Senator Elizabeth Warren to tech reporter Taylor Lorenz—appear to at least sympathize with this sentiment.
Patients are not the only ones suffering. A Wall Street Journal report from December 12th highlights the “aggravation and expense” with which doctors contend as they haggle with insurers for their patients’ care and their own livelihoods. The clinicians cited in the article condemn Thompson’s murder while also lamenting the system in which he—and they—are locked.
Maine ophthalmologist Anthony Ekong, for example, was recently informed by an auditing company that the insurer Wellcare had overpaid Ekong “for treating elderly patients with macular degeneration and macular edema.” The bill came to over $300,000. Ekong runs a solo practice; as he told the Journal, the unexpected bill meant he “would have to shut down or file for bankruptcy.” Wellcare suggested he make up the difference by billing his patients, many of whom “are elderly and struggling to get by.”
Andrew MacLean, who leads Maine Medical Association, reported that he regularly gets calls from doctors in the state “struggling with health insurers demanding so-called clawbacks for bills that had already been paid.”
In another jarring story from the Journal’s report,
Dr. Alan Nguyen, a spine specialist in Fort Myers, Fla., noted that when insurance-company doctors reject an MRI request, he now asks for their name and health provider identification number. “I tell them if a cancer is missed, then the patient will know who to sue,” wrote Nguyen. . . When insurers denied treatment, Nguyen observed, doctors were still left to deal with the patients and their pain.
The final line of the above excerpt is perhaps the most vital and unsettling. Doctors—especially those still in private practice—are immediately responsible to patients in ways insurance bureaucrats simply are not. Physicians actually meet and provide care for individuals who visit their offices, whereas insurers often treat patients as mere administrative burdens. The Kaiser report cited earlier noted that care is denied to patients for reasons that are very often opaque.
Connecticut state health plans, for example, cited a “lack of medical necessity” as the reason for rejecting merely 0.3% of 2021 claims. “Benefit not covered” was the stated reason for denying 3.9% of claims. Roughly another 10% of claims were denied due to technical or administrative problems such as incomplete or duplicate submissions. The lion’s share—49% of denied claims, 15.5% of total received claims among Connecticut plans—were rejected due to “all other miscellaneous.”
This combination of murkiness, volatility, and bureaucratic detachment has long characterized the American insurance market. It is contributing to the reshaping of health care itself in underappreciated ways.
Dr. Mark Davidian, a California radiologist quoted in the Journal report, has “despaired at the loss of agency when caring for patients.” When he finished his training 25 years ago, he explained, “doctors had their own practices. They called the shots.” They worked directly for patients and made clinical decisions with patient welfare as the lodestar. Today, the Journal notes, doctors “are increasingly employees of large hospital chains and find themselves trapped between insurers and their own cost-conscious management.”
Policy and financial pressures—of the sort that kept Dr. Patt on the phone with an insurer or Dr. Ekong in a tug of war with an auditor—nudge doctors away from private practice, leaving such messes to hospital staff. This means that doctors are less immediately accountable to patients. It degrades the medical profession and renders patients even more vulnerable.
All this goes a long way toward explaining the resentment against insurers. But as Betsy McCaughey argues in the New York Post, the resentment is mostly misplaced. Infuriating or tragic insurance policies are a symptom of a larger problem, which lies in Obamacare’s tight controls and false promises.
McCaughey notes that in 2013, before Obamacare regulations kicked in, insurers denied only around 1.5% of claims, according to the American Medical Association. Denials have since increased tenfold. Prior authorization requirements also escalated; as McCaughey writes, “according to House Committee on Energy and Commerce testimony, 80% of preapprovals that Cigna denied for Medicare Advantage customers were overturned on appeal — a sign that legitimate care is being withheld.”
McCaughey notes approvingly that many states are passing laws to limit prior authorization, but argues that Americans need to fundamentally reassess managed care. The ACA’s coverage expansion has mostly been in the area of managed care, despite virtually no evidence that it improves health outcomes or patient care. In a future post, I’ll delve further into why managed care has failed. It largely explains why the American health-care system, for all its impressive technology and practitioners, has few defenders.