On Monday, police in Altoona, Pennsylvania, arrested Luigi Mangione in connection with last weeks shooting death of UnitedHealthcare CEO Brian Thompson. When Mangiones identity became public, the online reaction around Thompsons death went into overdrive; unlike most shootings, this one has brought a stream of support for the suspected killer rather than for the victim, and Mangiones capture has only intensified that sentiment. Related:Mangione, 26, has since been charged with second-degree murder in New York, among other crimes, and has been valorized as a folk hero in many corners of the internet, though the killing of Thompson, 50, has also been widely condemned. After Mangine was arrested and identified, his following on X went from a few dozen followers to more than 300,000 overnight. From a flood of supportive memes on Instagram and X to a shooter lookalike contest this weekend in Manhattans Washington Square Park, making jokes about Thompsons death somehow came to be considered acceptable and appropriate.The widespread interest in Mangione demonstrates just how much built-up hate there is toward insurance companies: Americans are infuriated about the costs and complications of health care coverage, and Thompsons murder has brought that anger to the surface. To try to better grasp the reaction among Americans, Today, Explained reached out to journalist Bob Herman, who covers the business of health care at Stat News and has co-reported several investigations about UnitedHealthcare.Today, Explained co-host Sean Rameswaram spoke with Herman about UnitedHealthcares business practices, their place in the health care market, and why they have been a target of so much anger. An excerpt of his conversation with Herman, edited for length and clarity, is below. In the full podcast we also get into who Mangione is and what we know about his motives, why it took police five days to find him, and how they eventually did, so listen to Today, Explained on Apple Podcasts, Spotify, or wherever you get podcasts.Bob HermanUnitedHealthcare is the largest health insurance company in America, and it is part of a bigger company called UnitedHealth Group. UnitedHealthcare covers older adults on Medicare Advantage, they cover the poor who are on Medicaid, they sell Obamacare plans, and theyre also the plans that employers offer to their workers. Weve had a whole series this year called Health Cares Colossus that has looked at this massive company and how it has its tentacles everywhere. A lot of people recognize it for UnitedHealthcare, the insurance company. It is not just a health insurance company thats what its most known for, thats why its often reviled but people dont recognize all the other components that it owns. It owns a ton of medical practices. It either employs or is affiliated with one out of every 10 doctors in the country. It is the largest claims processor. They are everywhere.Sean RameswaramWhat was your reaction when you saw that Brian Thompson had been shot last week? Bob HermanIve never covered a homicide on my beat. Normally, this is a beat filled with white-collar crime, so this definitely has been outside of the norm. My colleague and I were watching UnitedHealth Groups Investor Day on Wednesday morning, just kind of a routine thing. Its a big meeting every year all kinds of investors and shareholders get together and they talk about their earnings for the year and its a big cheerleading routine. Normally Brian Thompson appears pretty early on, as the head of the insurance division for United. And then about an hour in, thats when I first got a text of a New York Post story saying that Thompson had been shot and killed. So a little bit more than an hour into it, thats when Andrew Witty, the CEO of UnitedHealth Group, the parent company, came back out and canceled the rest of the conference. We had never seen anything like it.Sean RameswaramAlmost immediately, people were celebrating this homicide. What was your reaction to that?Bob HermanThe reactions were pretty morbid. Pretty grim. The dancing on the death of somebody was pretty vile. But anyone who covers health care knows that people are fed up with the system. This is not new. This has been going on for decades. Even when the Affordable Care Act, or Obamacare, came into play 15 years ago, people still hated the system and its persisted since then. So peoples frustrations have been bubbling under the surface for so long. To say you were surprised by all the reactions, then I think maybe you had your head buried in the sand a little bit. Sean RameswaramBefore we talk about what this company does that might upset people, can you just tell us about the company generally? Bob HermanUnitedHealthcare is the largest health insurance company in America. They cover more people than anyone [its coverage] includes Medicare Advantage, Medicaid, Obamacare, and all the different types of employer plans out there. And theres a lot. Sean RameswaramWhich I imagine makes them pretty powerful in this market.Bob HermanYeah. Now, a lot of health care dynamics are local. The fights that often occur between health insurers and providers, like hospitals and doctors, are all about who has market share in a specific area. United might not always have the biggest market share in a given area, but nationally they are very powerful, they are very profitable. Theres no way of getting around them in pretty much any market. They exist almost everywhere in some capacity. Sean RameswaramAnd what do they do with that power? How do they throw it around? Bob HermanIf you have a UnitedHealthcare plan, you want them to negotiate better rates for you. Thats their primary function. And so they use some of that to try and drive better deals with hospitals and doctors and other types of facilities. Theyre also an insurance company and they happen to deny or delay claims as well. As an insurance company, the easiest way to make money is to make sure youre paying out fewer dollars. Now, there are laws in place, especially a federal law that says you have to spend a certain amount of your premium dollars on care for people. You just have to do it. But insurers have an incentive to stay as close to those thresholds as possible. They dont want to have to pay out more than they absolutely have to.Sean RameswaramYou just, of course, used two of the operative words in this story because as we found out, the shooter had inscribed three words on his bullets: deny, delay, and depose. Is this company known for its denials? Bob HermanEvery health insurance company out there is known for their denials, to some degree. Specific rates of denials are tough to come by, but insurers especially the for-profit ones that [trade] on the stock market have an incentive to deny care. There have been so many issues with denials over the years. My colleague Casey Ross and I reported on a big one within Medicare Advantage, the program for older adults. UnitedHealthcare is the biggest [provider] in Medicare Advantage, and over the past several years, theyve been using algorithmic prediction, predictive tools, and artificial intelligence to basically ramp up denials specifically in post-acute care, the care that somebody gets when they leave the hospital. So especially on that side of the coin, post-acute care denials have been a very big issue for United. Sean RameswaramWhat exactly does that mean, that theyre using algorithms and AI to deny Medicare Advantage [claims]? How do they do that? Bob HermanSo lets say someone goes to the hospital and then the hospital says, okay, you know, youre ready for physical therapy, occupational therapy, speech therapy. Lets send you to a rehab facility or a nursing home. So a person will go there and theyll start their physical therapy, and behind the scenes, UnitedHealthcare has used a tool called NaviHealth. Theres an algorithm within the company that looks at the patients demographics how sick they are, their history and tries to come up with some kind of prediction of how much time theyll need in that nursing home. Lets say its 16 days. Thats what the algorithm says after 16 days, you should be good. Now, if its used as a guide, thats fine. But in many cases, we found documents that said that United told their case managers, You have to stick to the algorithm.And thats where it becomes a problem, because if youre saying this algorithm spits out 16 days for somebody and theyre not ready to go home on the 16th day, if they cant even go to the bathroom themselves, if they still cant walk around but the algorithm says its time to ship them out, thats where its a problem. And thats whats happened. Then families are left with the decision of, do I pay out of pocket to stay at this nursing home to get the care that my mom or dad or grandparent needs? Or do I take them home with me and then risk having them fall or get hurt again and have to go back to the hospital or worse? So thats how the algorithms play in those types of situations. Sean RameswaramAnd people know this is happening and theyre mad about it? Bob HermanOn the Medicare Advantage side, most people actually dont. Theyre not aware as much about this because the algorithm happens behind the scenes. Its not like families are getting a sheet of paper saying, Hey, our algorithm says you have this much time here. They really dont find out about this until the nursing home says, Hey, your insurance is up and we have to kick you out now. The denials are very front and center in other insurance plans where they say, I know I need this back surgery or I need this prescription, and then United will come along with maybe a prior authorization which says, Hey, doctor, fill out more paperwork to make sure that this person needs this procedure or needs this drug. And then maybe theyll come back with a denial that says, Were not going to cover this procedure or this prescription drug. Thats where its most front and center for people, thats where a lot of the outrage comes from: those widespread delays and denials. Sean RameswaramWere talking about our eldest citizens who are often on the receiving end of these algorithms or AI initiatives that tell them theyve run out of care. Bob HermanAt least in our reporting it is for the Medicare Advantage it is the oldest, its the frail, often the poor, the oldest people in this country who often have no idea that this is going on. Once they find out, they can appeal; anyone can appeal any denial. But it is such an arduous process. If youre sick or injured, thats not something you want to be doing, and you might not have family to help you out either. So it is very clearly a problem. Sean RameswaramIs this a UnitedHealthcare-specific problem or is this a systemic problem? It feels like a systemic problem. Bob HermanThis is systemic. This is not isolated to just UnitedHealthcare. UnitedHealthcare gets the most criticism and heat for this because they are the largest and theyre a very common provider for any workplace plan. But there are other large insurers: Cigna, Aetna, all the Blue Cross Blue Shield plans, Humana. This is just how US health insurance works. This is a systemic issue, especially for the insurance companies that are on the stock market. They have a duty to make money for shareholders. And one of the ways that they do that is by making sure that they pay out fewer claims. The most-watched number on every earnings call for an insurer is whats called the medical loss ratio. Thats a number that says how much money from our premiums we spend on medical care, and lower is better. If its higher than expected, Wall Street freaks out. I think that kind of tells you a lot. Sean RameswaramThis has been an insane week for this industry. But do you think anything changes now, other than executives are going to have more security? Bob HermanCould this be a galvanizing event to broader health care reform? Its certainly possible, because the American public has made their voices very clear here. But this is completely dependent on a new administration, a new Congress. This is a federal policy issue. And if Congress doesnt act, then youre just going to continue to see more of this unless companies start to make changes on their own. But if they do, itll be around the edges. Itll be tinkering.Youve read 1 article in the last monthHere at Vox, we're unwavering in our commitment to covering the issues that matter most to you threats to democracy, immigration, reproductive rights, the environment, and the rising polarization across this country.Our mission is to provide clear, accessible journalism that empowers you to stay informed and engaged in shaping our world. By becoming a Vox Member, you directly strengthen our ability to deliver in-depth, independent reporting that drives meaningful change.We rely on readers like you join us.Swati SharmaVox Editor-in-ChiefSee More: