Creation: Proletarian Liberation Struggle Association Marxist Philosophy Group
On December 4th, a shooting shocked the entire United States. Brian Thompson, CEO of the country’s largest health insurance company “UnitedHealth Insurance,” was shot on the street and died after rescue efforts failed. The New York police found multiple shell casings at the scene, with words like “Delay,” “Deny,” “Defend” written on them—these are the usual tactics insurance companies use to deny coverage and refuse claims. The 25-year-old gunman, Luigi Mangione, wrote in his notebook: “These parasites deserve their punishment,… I must do this”; “Take out the CEO at the annual parasite money-counting conference,” which is “targeted and precise, and will not harm the innocent.” On the 9th, Mangione was arrested in Pennsylvania. When appearing in court in Altoona, he shouted to the media present: (the current health insurance system) “completely out of touch with reality,” “insulting the intelligence of the American people.” Thompson’s death was a great relief—his annual salary was as high as 10 million dollars, and he had boasted many times that his “greatest achievement” was increasing the insurance rejection rate by 10%. The American people have long hated this shameless, bloodstained parasite; moreover, the news of Mangione’s arrest ignited the long-suppressed anger of the masses towards the monopolistic capital’s reckless exploitation and extortion of workers within the entire healthcare system. They called online—“Free Luigi!” The people’s support is what reactionaries oppose. To protect their exploitative interests, the bourgeoisie boldly condemned this so-called “extreme malicious event threatening high-net-worth individuals’ safety.” Democratic politician and Pennsylvania Governor Josh Shapiro said: “In some dark corners, this killer is called a hero. Listen to me, he is not a hero.” Elon Musk, whose net worth just surpassed 400 billion dollars and who is about to assume the role of the “Department of Government Efficiency” in the Trump administration, openly stated: “Now everyone is calling this guy (Mangione—editor’s note) a hero, which is utterly disgusting. Insurance companies, like any other company, are obliged to maximize profits for shareholders, no matter how ruthless.” However, reactionaries are always cowardly in appearance. They bluster but are fearful at heart. Major insurance companies have removed executive information from their official websites overnight and built high walls around their premises. Under immense public pressure, the second-largest health insurance company, “Aetna Insurance,” was forced to withdraw its policy announced two days ago, which stated it would no longer cover excessive anesthesia costs in the future.
The United States is the country with the highest healthcare expenditure in the world. In 2022, total healthcare spending reached 4.46 trillion dollars, accounting for 17.3% of the GDP that year—if this expenditure were a separate economy, it would surpass Germany (4.456 trillion dollars) and Japan (4.42 trillion dollars), ranking second only to the US and China, and third in the world. Moreover, US healthcare spending has always been growing rapidly. From 1960 to 2022, US healthcare expenditure increased from 27.1 billion dollars to 44.646 trillion dollars, with an annual growth rate of 8.58%, growing 165 times over sixty years![^1] Given such high healthcare spending, should the American people be well protected in their medical care?—Some might think so. However, the answer is no. Among OECD countries (comprising European and American imperialist nations and their colonies), the US ranks second to last in average life expectancy. Additionally, within the US, about 46.6 million people, nearly 16% of the population, lack any medical coverage.[^2]
The US healthcare insurance system consists of government-run Medicare, Medicaid, and private commercial insurance. The former, namely Medicare and Medicaid, only covers about one-third of the population, targeting those over 65 and the extremely poor with income below 133% of the federal poverty line. Although these insurances are relief measures, they are not free. For example, to qualify for Medicare, employees must pay 1.45% of their wages as Social Security tax monthly, and still pay premiums after retirement—Part A[^3] is divided into no-premium (conditions: working more than 10 years and earning 40 “points”), $278/month, and $505/month tiers; Part B has $174.7 and $679.7 monthly tiers. It is estimated that retirees pay at least $2,096 annually for Medicare Part B premiums. If hospitalized, they must also pay out-of-pocket for Part A ($1,632) and Part B ($240)—because Medicare does not cover all medical expenses, insured individuals need to pay from their own pockets within certain “deductibles,” with the rest covered by insurance or jointly by insurance and the insured.[^4] Furthermore, Medicare does not cover all categories and medical institutions—excluding dental, ophthalmology, etc.; and due to its government and medical institution bargaining approach, some medical institutions refuse to accept government prices and Medicare patients. Here, we finally get a simple understanding of Medicare and the entire complex US healthcare insurance system—covering only a small portion of the population, with low reimbursement ratios, and insured individuals still bearing high medical costs (social insurance taxes, premiums, deductibles, out-of-pocket above deductible, etc., while private insurance costs are even higher[^5]) with limited scope of use. For the remaining two-thirds outside the elderly and the extremely poor, they can only purchase private insurance, mostly bought by employers deducting costs from wages. Although former President Barack Obama mandated that companies with over 50 employees must provide health insurance, the actual coverage rate among companies is only about 64%[^6]—many employers are reluctant to pay insurance premiums (though they can compensate by lowering wages), and some employees are unwilling to spend more of their already meager wages on useless insurance.
From 1999 to 2015, US employment income increased by 56%, while insurance premiums soared by 203%, with employee contributions rising by 221%. Besides constantly raising premiums, insurance companies also exploit Americans through various means: rejection of coverage—average rejection rate in the US insurance industry is about 16%, with UnitedHealth Insurance reaching 32%, the highest in the industry. To reduce claim probabilities and amounts, UnitedHealth uses the latest scientific technology, introducing AI (“artificial intelligence”) assessment tools in the “pre-approval” process, and many cases that pass manual review are still rejected by AI; bill padding—insurance colludes with medical institutions to inflate prices, and after “padding,” the bills appear to have higher insurance reimbursement ratios, but in reality, patients pay even more out of pocket than without insurance; “pre-authorization”—high-cost treatments require prior approval from insurance companies, causing many patients to be unable to receive timely treatment, and delays can lead to lack of compensation. The sweat and blood of the American people have been turned into money filling insurance company coffers, and it’s no wonder some say: “Yes, I condemn murder. Therefore, I condemn the rotten, despicable, greedy, bloodthirsty, and immoral healthcare insurance industry in the US. I condemn every related CEO, I condemn every politician who takes their money. They don’t destroy this system, but strive to maintain it,” “these insurance companies and their executives’ blood on their hands is even more than that of a thousand terrorists who carried out 9/11.”[^7]
Since healthcare insurance is so limited in function and so expensive, why do the American people still scrimp and save, spending a part of their already meager income to buy insurance? This is because, under the oppression of monopoly capitalism, the working hours of the broad masses are constantly extended, labor intensity increases, and the incidence of various diseases rises with the worsening of working and living conditions—taking cancer as an example, from 2015 to 2019, the incidence rates of breast cancer, pancreatic cancer, and uterine cancer increased by 0.6%–1% annually; prostate cancer, female liver cancer, kidney cancer, and HPV-related oral cancers increased by 2%–3% annually[^8]. However, the prices of medicine and medical services have not decreased with the development of medical technology—in fact, the US is the most technologically advanced country in medicine. In 2023, the number of new drugs listed in the US (127) exceeded the total of China (41) and Europe (55)—130%.[^9] Among the top 20 global medical device and diagnostic equipment companies, 12 are from the US, accounting for over one-third of the global market share. Conversely, due to the monopoly of medical enterprises, people’s healthcare costs remain high or even increase— in 2017, 18 US pharmaceutical companies were accused of monopolizing the market to manipulate drug prices, with some drugs skyrocketing from $20 to $1,849. Therefore, to avoid being completely impoverished or unable to afford treatment in the face of sudden illness, Americans often have no choice but to buy health insurance.
What should be the Marxist view on this shooting incident? As Marxists, we oppose Mangione’s assassination. However, this does not mean we believe Thompson was not justly deserving of his fate, nor does it mean we support the bourgeoisie and their mouthpieces in condemning Mangione for creating “terrorism”—the real, much larger-scale, white terror targeting the broad masses has long been carried out by the ruling class. It also does not mean we oppose the anger of the American people towards the healthcare insurance system or their movement against the bourgeois government persecuting Mangione. What we oppose is Mangione’s anarchistic individual terrorist act. This act is determined by his petty-bourgeois status—more precisely, by his wealthy petty-bourgeois background from an asset-owning family. Mangione was born into an bourgeois family in Baltimore, Maryland, and graduated from the University of Pennsylvania, making him a true “social elite.” However, for some reason—perhaps his family was unwilling to pay for his treatment—he stopped contact with his family months before the incident, his mother identified him as a suspect the day before his arrest, and his family expressed that they would “pray for Brian Thompson’s family” after his arrest—ultimately, he was struck by a severe back disease that could not be cured. The collapse of his previously comfortable life, driven by despair and a desire for personal revenge, led Mangione to plan the assassination of Thompson. This personal terrorist act, while stirring the masses and unleashing their long-suppressed anger at the rotten US healthcare system, cannot educate the masses to understand that the root cause of their blood-sucking high premiums and their helplessness in the face of illness lies in the capitalist system—the profit-seeking capitalist production relations and the resulting increasing poverty and instability of people’s lives; nor can it gather and concentrate “all the drops and streams of people’s righteous indignation”[^10] into actual revolutionary actions to eliminate this root cause.
Only socialist revolution is the only way out! (The only solution is the socialist revolution!)