Patients are struggling to pay ever-increasing sums for health insurance as huge corporations such as Minnetonka, Minnesota-based UnitedHealth Group report billions in profit and grant enormous pay to executives.

And then along comes a medical bill, and the insurer won’t pay.

This juxtaposition can feel enraging to patients. While it doesn’t excuse the fatal ambush last week of UnitedHealthcare CEO Brian Thompson — even company critics have strongly condemned vigilante justice, saying it’s not a solution — it does illuminate why the shooter has been celebrated by many on social media outlets over the past week.

The six-day gap between the killing of Thompson and capture of Luigi Mangione, a 26-year-old suspect, led the American public to rampant speculation on his motive with a public narrative coalescing around the shooter exacting a measure of symbolic justice on health care’s wealthy corporate elite. An internal police report quoted by the New York Times reinforced this idea, noting Mangione saw the killing as a “symbolic takedown,” based on his writings.

Yet public understanding of Mangione’s motives were fast-evolving Monday, with commentators raising questions of class and wealth. Mangione’s biography suggests a privileged prep school upbringing that contrasts with Thompson’s small-town Iowa roots and public school diplomas.

What remains is a week of vitriol over a health care system where too many people in the U.S. feel powerless against insurers and their affiliates, particularly during times when health plans deny coverage for care.

“Health insurers have never been popular because part of their job is not paying for care believed to be ineffective or low value,” said Paul Ginsburg, a health policy professor at the University of Southern California. “Perhaps in the age of social media, this is getting even more unpopular. We should consider whether the times call for performing this function in a more transparent manner.”

A majority of insured adults, particularly those in poorer health, say they’ve had trouble using their health insurance coverage, according to survey results published in 2023 by KFF, a California-based health policy group.

About one in six said they were unable to receive recommended care as a direct result of their coverage problems, the survey found, while about 15% said the trouble drove a decline in their health. Nearly three in 10 said they paid more than expected for care.

“The survey shows that the sheer complexity of insurance is as big a problem as affordability, particularly for those with the greatest needs,” KFF President and CEO Drew Altman said in a statement. “People report an obstacle course of claims denials, limited in-network providers and a labyrinth of red tape, with many saying it prevented them from getting needed care.”

Another survey of consumers, this one conducted annually by Gallup, found just 28% of respondents reported their health care coverage as “excellent” or “good” this year — 4 percentage points lower than the average for that question going back to 2001.

The acrimony on social media has been almost palpable. A poster on X displayed names and photos of several health insurance company CEOs on a “Wanted: Dead or Alive” poster — with the words “or Alive” crossed out. Another user displayed a chart showing denial rates for UnitedHealthcare and other insurers on a small subset of claims, and asserted that CEOs of other companies “may be next.”

Safety concerns amid the discord prompted Minnetonka-based Medica and Minneapolis-based UCare to close their offices this week.

The threats are clearly wrong, said Bill Foley, a former health insurance executive who now does patient advocacy work with Oakdale-based Cancer Legal Care. The truth is that some denials are justified, particularly those that stop fraud and abuse, he said.

Yet beyond the issue of denied claims, patient frustrations are rooted in financial strain. Some face crushing medical debts while many others are burdened by the inexorable growth of premiums and out-of-pocket spending requirements. One problem is that when claims are denied after the service is given, the resulting bills often are so large people can’t afford to pay and struggle to find help.

Last year, the Minnesota Star Tribune wrote about how one of Foley’s clients was confronted with a bill for $155,493 after his health plan denied coverage due to a lack of prior authorization for an interfacility transfer. The insurer agreed to pay the bill after being questioned by the newspaper.

Such situations leave patients feeling vulnerable, Foley said. Then they’re outraged to learn about huge pay packages for top health executives, whether at companies selling insurance like the corporate parent of UnitedHealthcare or health care providers like Mayo Clinic.

“There’s just that disconnect with people, feeding into this broader feeling of income inequality and powerlessness,” he said. “I think the money part is huge.”

While Mangione had medical problems, it’s not clear what role UnitedHealthcare may have played in his care or why he targeted Thompson specifically.

People who knew Mangione early in life said he played soccer in school. The suspect’s acquaintances in Honolulu — one of the last places he lived before the shooting — told reporters he had longtime spinal problems that were exacerbated in Hawaii.

According to acquaintances and Reddit posts from Mangione, he had a spinal-fusion surgery in 2023 to correct misaligned vertebrae that had possibly pinched a nerve, the New York Times reported. When the friend asked how the spine surgery went, Mangione replied “long story” and never elaborated. On Reddit, Mangione wrote that the surgery was not as scary as he was fearing, and “I knew it was the right decision within a week.” His posts mention a Blue Cross Blue Shield affiliate, but not UnitedHealthcare, which is the country’s largest health insurer.

Yet when Mangione was arrested, he had a 262-word handwritten manifesto with him that condemned profit-seeking American companies, specifically citing UnitedHealthcare, whose market value he said has grown while American life expectancy has not.

Comprehensive data on coverage denials, and the reasons for these decisions, has been woefully lacking, health policy experts say. Some statistics are available on coverage decisions by insurers who sell policies to individuals, but analysts say this data is difficult to interpret, partly because it’s a much smaller market than the employer health plans and government programs that provide coverage to the vast majority of Americans.

KFF found about 85% of insured adults surveyed support a requirement for insurers to report the frequency of denied claims and to disclose their denial rate to consumers. Federal law requires transparency data from most employer health plans, but the requirement remains largely unimplemented.

Another KFF survey published in October found family premiums for employer-sponsored health insurance are up 7% this year to an average of $25,572 annually, with workers contributing $6,296 to the cost. It’s the second year in a row that premiums are up 7%. Over the last 10 years, the health policy group says, the growth in the average premium for family coverage far outpaced inflation, 52% vs. 32%.

Patients, employers and the government pay because health insurance provides access to lifesaving and life-enhancing care. What many find unsettling, industry experts acknowledge, is how the underlying structure of this benefit is a highly technical legal contract between an insurance company and massive “payers” ranging from employers to the government.

Coverage terms like “medical necessity” that are vague and open to interpretation set the stage for disputes, said one former physician executive at a Twin Cities health insurer. This is particularly true when patients are sickest, and most in need of expensive care, the executive said.

“The consumer gets caught in the middle — that’s probably the main problem,” said the executive, who requested anonymity due to threats against insurers. “And they don’t know their appeal rights well. ... All of this plays out in a setting where health care is ridiculously expensive. It’s such a mess.”

Patients can request the contract documents, but don’t always know this, Foley said. The details can be hard to understand, ranging from prior authorization requirements to coverage exclusions. And patients find they get tripped up in a bureaucracy where automation can seem like a barrier to common sense.

“It’s often difficult for patients to understand — ‘Who’s really pulling the strings here?’ and ‘How do I make a difference?’” he said. It gets back “to this environment of the little guy versus the elites. ... People are probably quite certain that the higher-ups aren’t running into the same types of problems.”

Wisconsin resident Bil Schmidtknecht joined a protest outside parent company UnitedHealth Group’s pharmacy benefits management (PBM) business in September. His 22-year-old son Cole died earlier this year after he couldn’t afford to fill an asthma medication prescription. This is the sort of tragedy that could be prevented, Schmidtknecht believes, with reforms to the PBM market, of which UnitedHealth Group has a stake.

”Vigilante justice is not the way to do it — plain and simple,” Schmidtknecht said. “Do I have sympathy for Brian Thompson’s family? Well, hell yeah. I just lost my son. … I feel that pain for them, but where’s the pain for Cole and everybody else in this country who’s being affected by the company the guy worked for? That’s how I think about it. I don’t think it’s just, not in any way shape or form. And I’m not happy for it, either, because that doesn’t make things better.”

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