UnitedHealthcare, the health insurer whose CEO was murdered earlier this month, has spent decades fighting and winning political battles to maintain the for-profit health system status quo and kill any attempts to reform it.
The shocking murder of health insurer UnitedHealthcare (UHC) CEO Brian Thompson has ignited a fierce debate about the United States’ uniquely for-profit, insurer-dominated health care system, with the assassin having been apparently motivated by rage at its many injustices. What has largely escaped notice is UHC’s decades-long efforts, in concert with other parts of the health care industry, to blunt attempts to reform the system in a way that would benefit consumers and assuage this roiling anger.
From the earliest days of the Bill Clinton administration’s tilt at health care reform, through wrangling over Barack Obama’s dog’s breakfast of a health care bill, to the rise of Bernie Sanders and his Medicare for All proposal, UHC has been a Zelig-like presence, taking a central role in beating back efforts to change an often capricious and cruel system. Working with other insurers and for-profit health care entities, UHC has marshaled considerable resources — its money, lobbyists, and political connections — to prevent anything approaching the kind of public health care systems that exist in other countries from emerging in the United States, and to preserve a market-oriented system where the government’s role, if any, is to feed the profits of companies like itself.
A bitter irony is that the reforms UHC and others have bitterly fought for decades, had they been enacted, may well have prevented the kind of boiling over of popular fury that erupted in the reaction to Thompson’s killing. It’s impossible to know, but perhaps these defeated reforms could have not only saved the lives of countless patients over the years but also that of the late UHC chief executive himself.
Shaping Hillarycare
UHC had a front-row seat to Bill and Hillary Clinton’s doomed attempt to reform the US health care system, which took the form of “managed competition,” a market-based concept pushed by a broad swath of the industry that aimed to lower costs and get to universal coverage by encouraging and regulating competition between private insurers.
The company was one of six major HMOs whose CEOs were part of the “Chicago Group,” an informal working group advising and supporting the new administration as it embarked on the make-or-break effort. The CEOs “unanimously” agreed that only “harnessing the power of competitive forces” could rein in ballooning health care costs and urged Clinton to embrace “managed competition” as the solution, according to an April 1993 document held in the Clinton Presidential Library.
The Clinton White House didn’t take up all of the group’s ideas. One of their proposals, for example, was federally preempting “any willing provider” legislation, state laws that effectively stopped insurers from creating selective networks of preferred doctors. But managed competition ended up being the broad framework of Clinton’s business-friendly reform, which eschewed price controls or the kind of robust government role in health care common in other industrialized countries.
It did so even as the model had proved a failure in Minnesota, where it had been pioneered, but which by 1993 had seen a spate of double-digit rate increases and the poor and chronically unwell struggling to get coverage. As one local activist had put it to the St. Paul Pioneer Press, it was “the last gasp of the insurance industry to stay alive.” Or in the words of one executive from another insurer that advised on Clinton’s initiative: “For Prudential, the best scenario for reform — preferably even to the status quo — would be enactment of a managed competition proposal.”
UHC left other fingerprints on the reform effort, besides the fact that then first lady Clinton was indirectly invested in the firm at the same time she led the task force spearheading reform. A top adviser to both that task force and Ira Magaziner, the senior domestic policy advisor directing the effort, was Lois Quam, vice president for public sector services at UHC, a fact that raised eyebrows at the time given the obvious conflict of interest. An internal memo noted that Quam had stock options in UHC as part of her role at the company as well as “a generous salary and compensation package” and “an arrangement” to return after her stint in Washington was done.
“For Quam, it may not be easy to argue that her financial interest is ‘not so substantial,’” the memo stated, regarding efforts to get a waiver for her to join the working group. (Upon permanently leaving UHC in 2007, Quam publicly endorsed a public health insurance option, charging that the industry’s rapacious business practices in the interim had made it unavoidable.)
“Modernizing” Medicare
UHC next played a leading role in George W. Bush’s “modernization” of Medicare in 2003, which established a new prescription drug benefit that funneled billions of government subsidies to drug companies, who were entrusted to keep prescription drug costs down, aided by its barring of the federal government from negotiating for lower prices. The law, the Medicare Modernization Act, also created the Medicare Advantage program that has given private insurers a bigger and bigger role in the entitlement.
UHC was by no means the only player in a full-court press from Big Pharma, HMOs, and other for-profit health care interests pushing the bill, which saw them hire more lobbyists and spend more money than ever, to the tune of a combined $141 million. But it was a pivotal cog. UnitedHealth Group (UHG), UHC’s parent company, spent $1.3 million lobbying on the Medicare bill, according to a Public Citizen report, paying seven separate lobbyists to work on it.
Giving it extra clout was the fact that William McGuire, UHC’s chairman and CEO at the time, had been a major bundler for Bush, putting together more than $100,000 worth of donations for the then president. Meanwhile, Robert Wood, the former chief of staff to Bush’s Health and Human Services secretary, left the administration just before Congress wrangled over the bill to join a lobbying firm, where he proceeded to lobby Congress on behalf of, among other for-profit health care entities, UnitedHealth Group.
UHC also exerted pressure through its arrangement with the influential AARP (the Association of American Retired Persons, before it permanently made its name an acronym), which controversially threw its weight and that of its thirty-five million members behind Bush’s measure, running a huge nationwide ad campaign in support. From 1997 on, the AARP had contracted with UHC and other insurers to provide Medicare supplemental insurance, netting it a $161 million profit, which prompted resentful Democratic leaders Nancy Pelosi and Tom Daschle to suggest a conflict of interest.
Medicare Advantage, birthed from that 2003 legislation, has proven a financial boon to UHC, which now runs the largest Medicare Advantage health plan, accounting for 9.4 million enrollees, or 29 percent of enrollment in a program that draws $462 billion of federal spending. AARP has been criticized for saying little about the increasingly scandal-ridden program, even as it continues to earn big money from a cobranded Medicare Advantage plan with UHC — which, incidentally, has been a vocal opponent of any changes to it. UHC, meanwhile, has been the subject of at least three lawsuits alleging it used the program to take advantage of taxpayers for its own profit and fraudulently overbilled the federal government.
The company worked in the years ahead to keep its cash cow in place. In 2013, it won a major victory after a Medicare Advantage industry lobbying campaign led many Democrats and ultimately the Obama administration to reverse course on cuts to federal rates for the program. The about-face was engineered thanks to an advertising campaign in key states and more than 160 lawmakers writing the Centers for Medicare and Medicaid Services (CMS) to reverse course, an initiative led by industry trade group America’s Health Insurance Plans, which UHC was a part of until 2015. Most recently, it joined another industry-wide push against payment cuts, this time from Joe Biden’s administration, with the UHC chief executive personally making the pilgrimage to Capitol Hill to argue against it in 2023.
At the same time that the Medicare Modernization Act was being worked on, UHC wasn’t limiting its ambitions to the federal level. New York insurers at the time were largely getting away with ignoring a state law forcing them to pay medical claims on time, simply treating millions of dollars of fines over their serial tardiness as a business cost, secure in the knowledge that stricter legislation wouldn’t clear the Republican-controlled state senate. In 2003, the New York Post reported that the state’s health insurers had steered much of its $2.3 million worth of donations since 1999 to Republicans in the state senate, who tended to sit on health and insurance committees.
UHC alone gave more than $35,000 to various New York Republicans in that period. That included then governor George Pataki, senate majority leader Joseph Bruno, and Senator William Larkin, who would become president of the National Conference of Insurance Legislators — an association of state lawmakers whose main policy focus was insurance — and be named one of the hundred “most powerful people in the insurance industry” in North America by a trade publication.
Killing the Public Option
UHC had a more central role in watering down the next Democratic president’s crack at health care reform, namely Barack Obama’s effort early in his first term. Despite campaigning on a public option, Obama and Democratic leaders in Congress infamously wound up dropping the policy in favor of yet another series of regulatory tweaks that left the private insurer system in place while further fattening their bottom lines.
Again, insurers and other parts of the health care industry spent unheard-of amounts to recruit and pay for an army of lobbyists on Capitol Hill to shape the reform. Again, the industry lured people from Capitol Hill through the revolving door and into its payrolls to give it more sway in Congress. But UHC’s role this time was more direct.
A key statistic touted by opponents of the public option — that nearly ten times as many people as was estimated by the Congressional Budget Office would sign up for the program, potentially collapsing the private insurance sector — was cooked up by a UHC subsidiary. The company pressured its employees to agitate against the public option and other parts of the reform by contacting lawmakers, helpfully drafting model letters for them to send, and even directed them to join explicitly right-wing political events organizing against it.
The insurer made inroads with legislators’ offices, according to a BusinessWeek report at the time, feeding them talking points and policy advice that steered the reform debate away from ideas that would threaten insurer dominance. As part of this, it retained Daschle, the former Senate Democratic leader and public option proponent, who now gave the company advice it would use to kill the measure in exchange for pay. It parked an eighteen-wheeler full of top-of-the-line medical equipment near the Capitol in response to a proposed tax on insurers, and invited lawmakers to see the incredible things the industry was doing.
Infamously, mere hours after Pelosi backed off the public option in a 2009 interview with CNN, a top UHC lobbyist sent out an email to various Washington insiders inviting recipients to a $2,400-per-person “event with Speaker Pelosi at my home.”
Once again, the resulting reform, devoid of a public option, proved highly lucrative to UHC and the insurance industry. In a Bloomberg Government study covering the eighteen months after the law’s passage, five of the country’s major insurers, including UnitedHealth Group, saw their profit margins expand at a higher rate. By 2015, UHC executives openly celebrated that they had seen their earnings markedly rise in response to the rush of new Obamacare customers.
But its commitment was fickle. By 2017, the company, at this point the country’s largest insurer, had pulled out of nearly all of the health insurance exchanges that were key parts of Obamacare, deciding they were no longer profitable, and preempting further exits from competitors. The move sent tremors of concern for the future sustainability of the reform. In the interim, it had been a major donor to lawmakers like Senator Amy Klobuchar, who worked to chip away at funding elements of the law in deference to the health care industry.
Medicare for Some
By 2019, UHC and the industry had a huge problem on its hands. The political rise of Sanders gave renewed momentum to a push for a single-payer system, in the form of the Vermont senator’s Medicare for All proposal, which was cosponsored by fourteen of his Senate colleagues, including several Democratic presidential hopefuls.
“One of the things you said: ‘We’re really quiet’ or ‘It seems like we’re quiet.’ Um, we’ve done a lot more than you would think,” UHC’s then CEO Steve Nelson said in a February 2019 town hall meeting, in a recording obtained by the Washington Post, after an employee asked what the company was doing in the tug of war over Medicare for All. “You want to be kind of thoughtful about how you show up and have these kind of conversations, because the last thing you want to do is become the poster child during the presidential campaign.”
Through its membership in the Healthcare Leadership Council, UHG was part of the health care industry front group Partnership for America’s Health Care Future (PAHCF), created in 2018 to preempt Sanders’s policy and more or less every other Democratic proposal at the time to expand government-provided health care, such as the option to buy into Medicare or lowering its eligibility age to sixty.
With a $50 million war chest, it put out a seven-figure TV ad blitz warning against such reforms, a nearly $300,000 digital ad campaign targeting voters in battleground and primary states doing the same, and gave lawmakers whole talking points to copy and paste into their op-eds against the policy. Later, once the threat of Sanders had been neutralized, it turned its efforts to agitating against President Joe Biden’s public option proposal, which he had by then already stopped talking about.
While PAHCF attacked Sanders as “a leading advocate for upending our nation’s health care system in favor of starting from scratch,” UHG then CEO David Wichmann warned his signature proposal would mean “the wholesale disruption of American health care” that “would surely jeopardize the relationship people have with their doctors, destabilize the nation’s health system, and limit the ability of clinicians to practice medicine at their best” while having “a severe impact on the economy and jobs.”
Biden, who vowed to veto Medicare for All if it ever came to his desk, was the top recipient of UHG donations in 2020, and his campaign got a personal vote of confidence from several UHG executives in the form of maxed-out $2,800 donations. While UHG’s and other health insurer’s stocks plunged following the introduction of Sanders’s Medicare for All bill, they surged after Biden’s massive Super Tuesday primary victory.
UHC also spent considerable resources lobbying against the policy at the time, according to federal lobbying filings. The company spent $6.4 million lobbying the federal government on a plethora of issues between the second quarter of 2019 and the first quarter of 2021, among which were “single-payer proposals” and “Medicare for All.” Once Biden was inaugurated, in the $7.4 million it spent over the next six quarters, those were replaced with “proposals to expand health insurance coverage.”
For all of the talk from UHC and the anti–Medicare for All coalition that building on Obamacare was the better way to go, it worked during this period to undermine that reform too, while also fighting against other minor reforms made to better regulate the system while keeping the insurer-preferred system in place.
Overall, the firm put nearly $38 million toward federal lobbying from 2017 to 2024. A consistent focus of its lobbying for those first few years was repealing Obamacare’s health insurance tax, another measure to keep the program fiscally self-sustaining. Congress finally did so in 2019, a major victory for the health care industry, with the repeal taking effect in 2021.
Other high-profile matters included the Inflation Reduction Act — which partially repealed the ban on Medicare negotiating drug prices that had been put in place by Bush’s UHC-backed 2003 measure — as well as drug pricing reforms more generally and surprise billing, which Congress (mostly) eliminated in 2020. Though UHC officially opposed surprise billing, it also yanked away coverage for some out-of-network care in what was seen as a response to the measure passing.
The company continued its war against the public option not just at the federal level but at the state-level too. As Connecticut, the home base of the health insurance industry, tried to create its own statewide public option, UHC and other insurers moved to defeat it.
They formed an online campaign named “Insurance Matters to CT” to put out talking points against the idea and, not unlike in 2010, held a webinar urging its employees to call lawmakers and otherwise organize against an idea that would be “the path to single payer” and charge people “artificially low premiums.” According to that leaked webinar, the company was part of “three major coalitions” in the state working against the measure. In 2021, UHG and other insurers also wrote to Connecticut governor Ned Lamont, issuing a thinly veiled threat that they, as major employers, would leave the state if it passed. The bill died the next month under threat of Lamont’s veto, the third consecutive time it had been defeated.
UHC spent more than $550,000 lobbying the Connecticut government from 2019 to 2024 as the public option bill struggled to gain traction — major sums at the state level that far exceed spending by many other big firms. Insurance Matters to CT, meanwhile, has continued to argue against the idea, while also training its ire on the state’s Partnership Plan, which allows municipalities to join the state employee health care plan.
Avoidable Tragedies
UHC is not by any means the only corporate actor that has worked intensely to kill measures like Medicare for All, a public option, and other reforms that would have put Americans’ lives ahead of private profits. These efforts have always been successful precisely because they’ve seen the entire for-profit health care industry mobilize itself into a tidal wave of political pressure.
But the human tragedy that has struck UHC, as well as its ubiquitous and sometimes central role in these efforts, makes this history particularly notable. One can’t help but wonder how the terrible events of the past month might have gone differently had UHC and other insurers lost one or more of these political battles over the years.