Beyond Delay, Deny, Defend: A Call for Healthcare Reform

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On December 4, 2024, the tragic assassination of Brian Thompson, CEO of UnitedHealthcare, captured national attention. The messages etched into the 9 mm ammunition recovered at the scene echoed a grim narrative: “delay, deny, defend.” This phrase, familiar to critics of the insurance industry, encapsulates accusations that insurers employ obstructive tactics to deny or delay claim payments. The tragic event shines a harsh light on the deep-seated frustration many Americans feel toward the private health insurance system—a system that impacts millions yet inspires as much grievance as gratitude.

The U.S. Healthcare System

Overall, countries worldwide employ four primary healthcare system models, each with unique characteristics:

The Beveridge Model

• Key characteristic: Government-funded healthcare provided to all citizens.
• Example: Great Britain
• How it works: Taxes fund healthcare, and services are delivered by government-employed or contracted providers.

The Bismarck Model

• Key characteristic: Employer and employee contributions fund a health insurance fund.
• Example: Germany
• How it works: Private health insurance providers, often non-profit, offer plans to individuals and families. Government regulates the system to ensure affordability and accessibility.

The National Health Insurance Model

• Key characteristic: A single-payer government-run insurance program.
• Example: Canada
• How it works: A government-run insurance plan covers all residents, while healthcare services are provided by private providers.

The Out-of-Pocket Model

• Key characteristic: Individuals pay for healthcare services directly.
• Example: United States
• How it works: Primarily private insurance, with many individuals relying on employer-sponsored plans or purchasing individual policies.

However, the U.S. healthcare system is more complex, with a segmented approach catering to different population groups:

• Employer-Sponsored Insurance: A significant portion of the U.S. population receives health insurance coverage through their employers. These plans are typically purchased from private health insurance companies. While this system shares some similarities with the Bismarck model, key differences exist, such as the significant role of for-profit insurers and the potential for job-lock, where individuals may stay in less desirable jobs to maintain their health insurance benefits.

As of March 2023, approximately 60.4% of non-elderly Americans had employer-sponsored health insurance (ESI).         

• Individual Market: Individuals purchase insurance plans directly from private insurers.

As of 2023, an estimated 18.2 million people were enrolled in individual market plans.         

• Medicare: A federally-funded health insurance program primarily for individuals aged 65 and older, as well as certain younger people with disabilities. While similar to Canada's National Health Insurance (NHI) model in its single-payer structure, Medicare differs in its coverage limitations and the role of private supplemental insurance plans, often required to cover gaps in Medicare benefits.

As of March 2023, approximately 67.8 million people were enrolled in Medicare.         

• Medicaid: A joint federal-state program providing health coverage to low-income individuals and families. While sharing similarities with Canada's National Health Insurance model in its goal of providing universal coverage, Medicaid operates with varying eligibility criteria and benefit packages across different states. This can lead to disparities in access and quality of care, depending on an individual's state of residence.

As of August 2024, approximately 79.4 million people were enrolled in Medicaid and CHIP (Children's Health Insurance Program) nationally.        

• Government-run: The U.S. operates several government-run healthcare systems, including the Veterans Health Administration, Indian Health Service, and healthcare within prisons. These systems, while similar in principle to the Beveridge model, often face challenges related to funding, staffing, and access to specialized care, particularly in rural and underserved areas.

Indian Health Service serves approximately 2.9 million American Indians and Alaska Natives.        

• Uninsured: A significant portion of the U.S. population remains uninsured, often due to high costs, eligibility restrictions, or a lack of employer-sponsored coverage. This lack of insurance can lead to delayed or forgone care, financial hardship, and poorer health outcomes.

In 2023, approximately 8% of the U.S. population, or about 26 million people, were uninsured.        

The Scale of the Private Health Insurance System

The U.S. private health insurance industry is enormous. Companies like UnitedHealthcare insure tens of millions of Americans, influencing nearly every interaction patients have with the healthcare system. Private insurers act as gatekeepers, negotiating prices, determining covered services, and enforcing policies like prior authorizations.

Proponents of this model argue that it offers flexibility, choice, and innovation. Employers can tailor health benefits, and consumers can select plans suited to their needs. Insurers also claim to curb wasteful spending by negotiating competitive prices and enforcing care guidelines.

A System Under Siege

For millions of Americans, the system feels adversarial rather than supportive. “Delay, deny, defend” reflects the perception that insurers prioritize profits over patients. Stories of families bankrupted by denied claims, patients waiting weeks for prior authorizations, or life-saving treatments deemed “medically unnecessary” are alarmingly common.

Consider this: while the average U.S. worker contributes thousands annually to insurance premiums, many still face high deductibles and out-of-pocket expenses. A 2023 survey revealed that over 40% of insured adults delayed or skipped care due to cost—a grim statistic for the wealthiest nation on earth! The grievances run deeper than individual hardships; they reflect systemic inequities that tie access to care to employment status, income, and geography.

A World Apart

To understand the roots of this dissatisfaction, one must consider global comparisons. Nations like Canada and the UK provide universal coverage through public systems, largely funded by taxes. Patients in these countries rarely face bankruptcy over medical bills, and healthcare is treated as a right rather than a commodity. While these systems grapple with issues like wait times, they deliver care with less administrative complexity and at significantly lower costs than the U.S. model.

The stark contrast invites reflection: if other nations can achieve equitable, cost-effective care, why can’t the U.S.? Critics of the American system argue that private insurers are deeply entrenched in policymaking, with lobbying efforts that maintain the status quo.

Why the System Breeds Grievance

The U.S. health insurance system is uniquely positioned at the intersection of healthcare and capitalism. For some, this intersection represents the best of both worlds—market-driven innovation and broad service options. But for others, it represents a moral failing, where lives are measured against profit margins.

The dissatisfaction stems from several sources:

1. Complexity: Navigating premiums, deductibles, networks, and co-pays is overwhelming for many.
2. Cost: Even with insurance, Americans pay more out-of-pocket for healthcare than citizens in any other developed country.
3. Injustice: Access to care often depends on socioeconomic status, leaving vulnerable populations disproportionately underserved.

In the wake of Brian Thompson’s assassination, it’s vital to channel collective frustration into constructive dialogue. The U.S. must confront critical questions: Can private insurers adopt reforms to become more patient-centered? Should the system embrace hybrid models that integrate universal coverage with private options?

Reform is neither easy nor swift, but the stakes are clear. Without change, grievances will continue to mount, and the healthcare system risks losing the trust of those it serves.

A Wake-Up Call

The tragic assassination of Brian Thompson underscores the deep-seated frustrations within the healthcare system. If law enforcement concludes that the motive was a personal grievance related to health insurance, it serves as a stark reminder of the human cost of a system often perceived as prioritizing profit over patient care.

The U.S. healthcare system is a complex tapestry of public and private programs, marked by both innovation and inequity. While it offers cutting-edge treatments, it also leaves millions struggling with access, affordability, and quality of care.

Let us not waste this moment. Instead, let it inspire conversations about how to build a system that prioritizes people over profits. A system where “delay, deny, defend” is replaced with “heal, help, serve.”