In December 2024, a masked gunman shot and killed UnitedHealthcare executive Brian Thompson in the streets of New York City. The murder roiled the internet. Although most social media users agreed that nothing could justify murder, the crime ignited a furious public debate about health insurance companies like United. For most Americans, private health insurance is a fact of life. You go to the doctor, and someone asks you for your insurance information before anyone takes a look at you. You go to the hospital and it’s the same story. Insurance companies have great power over a person’s life. They can — and do — deny necessary care, or saddle people with medical bills that they can’t afford to pay. Most people won’t take matters into their own hands the way Thompson’s alleged killer, Luigi Mangione, did last year. But the rage simmers. (Mangione has pleaded not guilty).
Beneath that rage lies a much older story about inequality in the United States. Good healthcare is a luxury good here, not a human right. Care depends on where you live, and how much money you make; it depends on your employer or even the whims of state legislators. The system is propped up by a political economy that creates a class of disposable person: people on the margins, deprived of power over their own lives. Thompson’s killing briefly forced that reality back out into the open. The fifth anniversary of COVID should extend the conversation. When I began to report and research my book, Disposable: America's Contempt for the Underclass, I knew that it would not be a meaningful retrospective on the pandemic if I didn’t scrutinize the role our patchwork healthcare system played in making people vulnerable to the virus.
To be disposable in America is to be tired, struggling, and often sick. As frontline medical workers tried to save lives from the virus, they had to operate within a political economy that was working against them at every turn. People told me that their loved ones delayed emergency care because they feared the cost — sometimes with deadly consequences. Others said their problems began long before COVID. Their stories tell us that disposability is a flexible state. Anyone can fall into it, dragged down by job loss or rising rents or a medical crisis. No one is immune, not even the young. Five years after COVID reached the U.S., we’re still reckoning with a political failure to guarantee healthcare to everyone.
A single act of reckless violence won’t end disposability. We owe something more to the COVID dead, and to the living, who are still subject to a healthcare system that prioritizes profit over human life.
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Such is the care America provides its disposable, who survive on the nation’s scraps. From America’s inception, wealth has flowed upward, whether from slave to master or from worker to boss. The disposable person stands in a chasm cut by centuries of movement. With great effort she can scale the walls: the victory of emancipation, and the gains won by the labor movement, have forced America to embody more of its self-professed democratic ideals. Yet those walls are still unacceptably high, and the disposable have far to reach before they know security. To get there, they must battle a political economy that sees them not as a people but as a site of extraction. When they are healthy, the system will siphon wealth from their labor. In sickness, their bodies are all that is left. Here at the end, the system sucks up its last profits until she is spent.
The Affordable Care Act reduced the ranks of the uninsured and kept people alive, but it’s still possible to slip through the cracks in the law. As a market-based attempt at reform, the ACA was never that radical; it did not remove the profit motive from health care. Yet it, too, had enemies. The ACA provoked ludicrous hostility when first introduced: On her popular Facebook page, former Alaska governor and vice presidential candidate Sarah Palin accused President Obama of creating “death panels” to exterminate seniors and the sick. Palin’s precise scenario never came to be, but the ex-governor hadn’t quite invented the dynamic she allegedly feared. Death panels do exist. They predated the Affordable Care Act and survived its implementation. All countries ration health care to some extent, but the U.S. “is unique because of the complex, sometimes hidden, and frequently unintended ways it rations care,” wrote Beatrix Hoffman in the introduction to her 2012 book, Health Care for Some: Rights and Rationing in the United States Since 1930.
The U.S. recognizes no universal right to health care, Hoffman observed; instead, it is only guaranteed for some groups, like veterans who are eligible to enroll in the VA system. Citing the scholar David Mechanic, Hoffman distinguished between explicit rationing, where official rules govern the distribution or denial of care, and implicit rationing, which is broader, and encompasses “different access to care” depending on a person’s insurance status and ability to pay. Though Americans fear explicit rationing, the consequences of implicit rationing rarely make headlines, Hoffman wrote. That’s beginning to change, due to public outcry and the rising popularity of proposals like Medicare for All.
Though a mythology of personal liberty can obscure the extent to which the U.S. rations care, news outlets and some politicians are pulling back the veil. Reality is becoming difficult to ignore, although power lies, still, with the entities like private health insurance companies. Every day, insurance companies ration or deny care, and they don’t yet fear the consequences of their actions. In 2023, the news website ProPublica obtained a damning recording: in it, a nurse employed by UnitedHealthcare told her colleague that a doctor under contract had decided that a patient’s ulcerative colitis treatment was no longer necessary. The colleague laughed. “I knew that was coming,” he said.
The Affordable Care Act softened the cruelty of the American health-care system, but it did not subvert the system itself. To the bill’s defenders it is monumental legislation, and perhaps in some sense it is. At its core, however, the law further binds Americans to the market and to their employers, a form of mass labor discipline. To it we are not people first but rather consumers, and the distinction matters.
Because the American health-care system is driven by profit, it generates conditions that may cause a person to fall into insecurity or even outright poverty. The line that separates a middle-class life from that of the disposable can look especially thin with the arrival of a large medical bill or significant medical debt.
E.L., who asks to go by her initials only, can recall a “bodily relief” when she traveled to the UK on a student visa and could use the NHS, just as I once did. “We didn’t have tons of money growing up. My dad was a special ed teacher and my mom worked in a warehouse,” she explains. “This idea that you could get a bill out of nowhere that would put you in bankruptcy or make it impossible for you to live in a kind of normal way, meaning to not have to worry about going to a grocery store, that was so sharp in my mind,” she adds. When she left the U.S. for England, the knowledge that she would never be surprised by a massive medical bill made life “viable.” Nevertheless, old habits lingered. She says that at first she avoided the doctor, a legacy of her time in the U.S. “You just wait till things are bad and then you try to triage it,” she continues. In the UK, she had to learn “a new way of thinking about health care because it wasn’t something reserved for emergencies and rich people.” In the U.S., she says, “poor people don’t get to have dignity in health care. You just have to beg.”
In addition to her time in the United Kingdom, E.L. spent a significant period of time elsewhere in Europe before returning to the U.S. to work for a campus of the University of Maine. Almost by luck, she chose a good health insurance plan that covered most of her needs, but her position ended during the first year of the pandemic and she lost her plan. She managed to get onto her partner’s insurance, and says it wasn’t as good. “I was having a chronic health issue, and I had to go to get ultrasounds. I would go because my fear of getting really sick was greater than my fear of paying the bill, or getting the bill and not being able to pay it,” she tells me. “But every time I would go, I would just get sick to my stomach because I would be so anxious about what it was going to cost.” One day she received a medical bill for $6,000 in a year when she’d made less than $14,000. She and her partner had moved from rural Maine to the more expensive city of Portland, where an apartment cost them $1,700 a month. Everything went to the landlord, and there was nothing left over to cover their health care. During the pandemic, she rationed her visits to the doctor because the bills cost too much money on top of insurance and rent. A disposable person can be anywhere, even in the world of higher education; degrees are often no bulwark against the cold.
She and her partner have since relocated to Ireland for work. “As immigrants, we have to have private health insurance,” she explains, but costs are more tightly regulated than they are in the U.S. Instead, they pay a certain amount per year, and their health-care costs are capped. The contrast with the U.S. remains jarring. “One of my mom’s bills just for the anesthesiologist to check on her—not for the anesthetic, but just for the check from the guy beforehand—was $10,000. That was the part we were supposed to pay,” she says. “My dad, I think he made $44,000 a year when he retired. How could you pay that?” Few can.
The nation’s disposable know they can’t count on the health-care system. That’s to the clear detriment of the disposable person, but it also sets up a difficult situation for health-care providers, who must operate within an inhumane system. The emergency room has come to function as a social safety net in an era where few such safeguards exist. Within the hospital itself, providers confront not only the failures of the health-care system but the broader capitalist system of which it is a part. An occupational therapist, who asked to remain anonymous for professional reasons, struggled with proper protective gear at her rural hospital. “We had forty beds,” she explains. “We ended up, because no one really knew how this virus was transmitted at that point, walking in full lead gowns and face shields and any kind of respirator we could find because we didn’t have the equipment that bigger hospitals had.”
At the same time, she struggled with her own health-care costs. Advanced degrees have become an industry-wide expectation for people in her field, she tells me, which meant that many leave graduate school with high student loan debt. “You have these Medicare and Medicaid cuts, which are primarily providing funds for you as a therapist to be reimbursed,” she adds. “So the money that you actually make coming out of school is very limited. In a lot of places, to save money, they are going to put you on an hourly schedule, and if you don’t have a patient they send you home.” She estimated that she made $1,300 per paycheck, as her health insurance siphoned $500 of her salary per month.
Though that wasn’t a poverty wage, she had little left over to cover whatever insurance did not. “I’ve had abscesses in my mouth and things that need to be taken care of medically that I’ve put off, and had infections,” she says. An incident at work required stitches, which she couldn’t afford. She had to ask family members for financial help. “The big emotion for me is hopelessness because I see this system from two different lenses, from a patient’s perspective, as well as my own perspective,” she continues. “I in some ways live some of those realities with them, and I sympathize with them. I think if it’s bad for myself, how much worse is it for someone who maybe doesn’t have the privilege of being able to go and get an education, or the privilege of being able to have some of the safety nets that I’ve had. And that is something that I struggle with.”
The pandemic and its consequences argue for a transformation. The need to ration health care, or to avoid it altogether, was too common before the pandemic, and the consequences were just as potentially fatal. COVID merely raised the stakes.
In America, excess death has become ordinary. Our health-care system is too often a slender lifeline in a time of crisis. Too fragmented and expensive to meet the needs of the many, the system reserves the best care only for those with the means to pay for it. For some others there’s GoFundMe, but for most there’s nothing. The safety net is too weak to catch us all. The dogma of personal responsibility poisons health care in America, and transforms even basic care into luxuries. Our broken health-care system is no impediment to national wealth, we can see that much clearly; America is a rich country. Equality is another matter. Not only does our health-care system contribute to inequality, industry opposition to health-care reform reflects a ruling class commitment to maintaining inequality at all costs. Before COVID, transformative health-care reform had few champions among the powerful. Politicians like Bernie Sanders and Representative Pramila Jayapal of Washington have helped keep Medicare for All alive as an idea, but although they have committed supporters, these voters haven’t yet coalesced into a mass movement. There’s still time, though, for COVID to change that. For unnecessary death to feel extraordinary, for outrage to generate real change. “There’s too many people out there that are having these problems like I am,” the occupational therapist says. “It’s just a matter of time before something gives."
