Translated by ChatGPT
Lianhe Zaobao
2026-09-05
The author, Luo Siling, is a freelance writer based in the United States
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Over the past decade or so, the ultimate result of U.S. health insurance reforms seems to have been little more than an increase in the profits of the private insurance industry, while the structural problems of high medical costs, low efficiency and inequality have continued to worsen. The three words Mangione engraved on the bullet casings could be said to have voiced the public’s resentment toward health insurance. This is the fundamental reason why he has been regarded as a modern-day Robin Hood.
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On August 14, the gunman who shot and killed UnitedHealthcare CEO Brian Thompson, Luigi Mangione, pleaded guilty at a federal court hearing. In the early morning of December 4, 2024, Thompson was shot and killed outside the New York Hilton Midtown hotel in Manhattan, New York. At the time, a masked gunman fired several shots from behind and then fled. The bullet casings were engraved with the words “delay, deny, depose,” a variation of the slogan commonly used by critics of the U.S. insurance industry, “Delay, Deny, Defend,” alluding to the need to abolish (depose) the insurance industry’s practice of denying claims.
Five days later, Mangione was arrested in Altoona, Pennsylvania. He came from a wealthy Italian-American real estate family in Baltimore and had worked as a data engineer. He had long suffered from severe back pain. At the August 14 hearing, he acknowledged his motive for committing the crime: “After suffering years of severe back pain following a spinal fracture, struggling through the health insurance system, and witnessing countless others go through similar experiences…”
However, after the shooting, American social media quickly mythologized the masked gunman, with nicknames such as “modern-day Robin Hood” even appearing. A large number of posts called him an “anti-insurance crusader” and “someone who sought justice for the people.” After his arrest, his fans raised hundreds of thousands of dollars for his legal defense. Polls showed that although most Americans believed murder was unacceptable, about 41% of young people aged 18 to 29 considered it “acceptable”; about 25% of adults expressed sympathy. At the same time, the incident also stirred up long-standing resentment among Americans toward health insurance.
The U.S. health insurance system is essentially a century-long “profit experiment,” transforming healthcare from a public responsibility into a huge private industry and giving rise to structural crises of high prices, low efficiency and inequality. Sociologist Paul Starr, in his classic book The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (published in 1982 and awarded the Pulitzer Prize in 1984), discussed the design of the U.S. health insurance system, which originated from the “rise of sovereignty” of the medical profession in the 19th century. It went through marketization and government intervention in the 20th century and evolved into today’s situation dominated by private insurance and corporate monopolies.
In the early 19th century, American medicine was filled with quacks and low-level practitioners, and doctors ranked below lawyers in social status. In 1847, the American Medical Association (AMA) was established, promoting standardized education and elevating medicine into a “sovereign profession” — an autonomous sphere independent of the market, government and public. Doctors proclaimed themselves “above the market,” emphasizing ethics rather than profits, and won public trust, shaping the early system: private practice, no advertising and no price competition. However, the Great Depression of the 1930s disrupted this balance. Amid mass unemployment, hospitals faced closure, while nonprofit insurance organizations such as Blue Cross and Blue Shield emerged, promising to pay hospital expenses in exchange for stable income. Doctors initially resisted, viewing insurance as “corporate medicine” and a threat to professional autonomy. But postwar economic prosperity and tax incentives, such as the tax exemption for employer-provided insurance, accelerated commercialization. By the 1950s, private insurance covered half the population, and hospitals shifted from charitable institutions to “semi-corporate” entities — administrative expenses soared from 5% before the war to 20%.
Starr emphasized that this transformation was not inevitable: Europe chose national insurance, while the United States, because of the AMA’s opposition to “socialized medicine,” favored a market model, laying the foundation for profit-first principles. This created a conflict between “the profession vs. the market,” resulting in various problems: doctors became industrial laborers, the healthcare system became fragmented, administrative burdens became heavy, medical costs became expensive, and even waves of hospital mergers emerged, amplifying monopolies.
In the latter half of the 20th century, the transformation of the U.S. healthcare system accelerated. In 1965, the government introduced federal health insurance, but private insurance still dominated 90% of the market. Although the Health Maintenance Organization Act of the 1970s was intended to control costs, it strengthened corporate involvement: giant companies rose, using prepaid arrangements to reduce payments, with profit margins reaching 15% to 20%. From then on, insurance companies, hospitals and pharmaceutical companies became the core players, with decisions prioritizing shareholder returns rather than patient welfare.
Today, the U.S. healthcare system is the only system in the world primarily driven by profit, resulting in misaligned incentives among various stakeholders as they pursue profits, collectively driving up overall costs: Health insurance companies maintain profits through high administrative expenses, accounting for 18% to 20% of total spending, and strict claims reviews. In 2024, seven major insurance companies recorded $71.3 billion in profits, while paying their CEOs more than $146 million in compensation. Hospitals, meanwhile, rely on high pricing strategies. For example, national hospital spending surged to $1.52 trillion in 2023, an increase of 10.4% year-on-year, while average net patient revenue rose from $192.5 million in 2019 to $242.5 million in 2023. Pharmaceutical companies extract excess returns through patent protection and frequent price increases. In 2024, U.S. spending on medicines rose from $437 billion to $487 billion, an increase of 11.4%, while the median price of 775 brand-name drugs increased by 4.5% during the same period, far exceeding the inflation rate.
It can be said that under the market logic of profit first, health insurance companies, hospitals and pharmaceutical companies have become profitable or even highly profitable entities. With these factors working together, healthcare in the United States is becoming increasingly expensive. In 2025, per-capita healthcare spending is expected to reach approximately $14,900, accounting for nearly 18.5% of GDP.
In 2010, drawing on the Massachusetts health insurance model of 2006, the Obama healthcare reform was formally implemented. Although it was rolled out nationwide and expanded coverage, reducing the uninsured rate from 16% to 8.2%, it did not alter the core design of health insurance and instead continued to strengthen the dominance of private insurance. For example, in 2025, total federal subsidy spending was approximately $107 billion. These subsidies were distributed through insurance exchanges with the aim of making insurance affordable. Of these plans, 90% were provided by private insurers, further reinforcing the profit-oriented model. The profits of insurance giants surged from approximately $4.8 billion in 2010 to approximately $15.1 billion in 2025, about 75% of which came from government subsidies, yet they used “prior authorization” to reject about 20% of claims, delaying treatment. As Starr said in his book, such reforms have intensified commercialization.
In 2025, Trump publicly accused Obamacare of being the culprit behind rising premiums and signed the One Big Beautiful Bill Act. This is the core of his healthcare reform and the largest federal healthcare spending cut in U.S. history. It is expected to cause the national uninsured rate to rise by 3.3 percentage points, with a total of 7.5 million to 10 million people losing insurance coverage. Those who lose coverage will have no choice but to turn to expensive commercial plans, further reinforcing the priority of private profits.
Whether it is the Democratic Party’s pursuit of “fairness and equality” or Trump’s move toward the “market,” over the past decade or so, the ultimate result of U.S. health insurance reforms seems to have been little more than an increase in the profits of the private insurance industry. The structural problems of high medical costs, low efficiency and inequality have not only failed to disappear but have continued to worsen. The three words Mangione engraved on the bullet casings could be said to have voiced the American public’s resentment toward health insurance. This is the fundamental reason why some Americans regard him as a modern-day Robin Hood.
The author is a freelance writer based in the United States
Luo Siling
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