In an email to UnitedHealth Group’s 440,000 employees last week, chief executive Andrew Witty highlighted messages from a breast cancer survivor and five other patients praising the insurer in the aftermath of the assassination of one of its top executives.
Since Brian Thompson, who ran the Minnesota-based group’s vast UnitedHealthcare insurance unit, was shot dead in midtown Manhattan earlier this month, however, sympathy for the country’s largest health insurer, which covers about 50mn Americans, has been in short supply.
The actions of the alleged shooter — 26-year-old Luigi Mangione, an Ivy League graduate who suffered from a lower back condition and griped in a manifesto about how companies like UnitedHealth “abuse our country for immense profit” — has intensified one of America’s thorniest national debates: how to fix a healthcare system many see as broken.
Mangione, who has been charged by New York prosecutors with murder, is expected to plead not guilty, his attorney has said.
The sweeping discontent towards the US healthcare system is no surprise, according to Mark Bertolini, the former chief executive of health insurance company Aetna, who now runs start-up Oscar Health: “What happened to Brian is unconscionable but the anger from patients is justified,” he said.
The problem, Bertolini said, results from “the war between healthcare providers and the insurance companies” about what treatments are covered and who bears the cost. Patients are “caught right in the middle” of a complex, bureaucratic system where medical bills and out-of-pocket expenses not covered by insurance are rising but people feel worse about the provision and quality of care, he added.
Healthcare spending per US resident is $12,000 a year, at least 50 per cent higher than any other rich country, yet it ranks 60th in the world for life expectancy, according to the Peterson-KFF Health System Tracker. A version of that statistic was cited by Mangione in a handwritten missive he was carrying when arrested in Pennsylvania. UnitedHealth said that Mangione was never a member of one of its insurance plans.
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Insurers themselves are just one part of the sprawling US healthcare landscape. Around three-fifths of Americans get coverage through their job, in which their employer subsidises part of the insurance premium, according to Kaiser Family Foundation. Others rely on federal or state programmes, such as Medicare for the elderly and Medicaid for low-income individuals.
The largest recent shake-up to US health insurance came with the enactment of the Affordable Care Act, widely known as Obamacare, in 2010, which expanded Medicaid coverage. It also created government-run health insurance marketplaces, and restricted insurers from denying coverage based on pre-existing conditions.
The legislation has meant that tens of millions of previously uninsured Americans are estimated to now have insurance.
Employers or the government play a key role in choosing which treatments to allow or restrict on different plans. However, insurers face the unpopular task of enforcing these policies by managing claims and determining eligibility for tests and treatments.
A KFF survey published last year found that 18 per cent of insured US adults had claims denied in the past year. Nearly three-quarters of 210 healthcare staff surveyed for an Experian Health report, released in September, said claim denials were on the rise.
More than 20mn Americans owe some medical debt, according to an analysis by KFF — in total they owe $220bn. Of those with debt, about 14mn people owe more than $1,000 and about 3mn people owe more than $10,000.
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Joseph Betancourt, a primary care doctor at Massachusetts General Hospital who also serves as president of the Commonwealth Fund, a healthcare non-profit, said all too often he orders an MRI scan for a patient but the insurer tells him a cheaper CT scan or an X-ray is preferable. Outright denials of complex procedures occur less often but are even more controversial, he added.
Betancourt said he understood the need to prevent the use of unnecessary and expensive tests, medicines or procedures to control costs but he said increasingly insurers were “overstepping the mark and interceding in clinical decisions”.
Another of the biggest US health insurers — Anthem Blue Cross Blue Shield — last week reversed plans to limit coverage for anaesthesia care for surgery that carried on beyond a certain time limit in three states, including New York. The group said in a statement that there has been “significant widespread misinformation” about the policy and as a result it had decided not to proceed.
“The part that makes this acutely painful for patients and providers is when these insurers are for profit, and they are making choices around cutting costs, yet at the same time generating incredible profits for shareholders,” said Betancourt.
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UnitedHealth Group, which generates around three-quarters of its revenues from its insurance unit, reported record net profits of $23.1bn last year. UnitedHealth’s profits have taken a hit this year due to changes to certain Medicare plans, but in 2025 they are projected to rise to $26.1bn, according to analysts’ consensus estimates.
According to a recent Pew Research Center survey, Americans view the affordability of healthcare as the second-biggest problem facing the country — behind only inflation, and ahead of issues like illegal immigration and gun violence.
In a column for the New York Times, published on Friday, UnitedHealth’s Witty acknowledged that “the reasons behind coverage decisions are not well understood”, adding: “We share some of the responsibility for that”. UnitedHealth said it approves 90 per cent of claims upon submissions and only 0.5 per cent are reviewed due to medical reasons.
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Matt Eyles, a healthcare industry veteran who previously led AHIP, an industry body for health insurers, said the sector bore the brunt of the criticism as it was “faceless” in contrast with a hospital “that you drive past on your way to work, where you or your friends or family had to go to the emergency room”.
Given the discontent expressed in the past week, Dan Mendelson, chief executive of Morgan Health, a division of JPMorgan investing in innovations to employer-sponsored healthcare, said that “it was striking to see how in the [November] electoral cycle healthcare didn’t really come up”. “The only way of changing anything is with major legislation — and I’m not sure the enthusiasm is really there,” added Mendelson.
“It’ll be interesting to see how long this firestorm takes to blow over . . . and when it does if anybody changes anything,” said Bertolini.
