Unpacking the rage against insurers

The December killing of UnitedHealthcare CEO Brian Thompson and the often laudatory response to it online has the industry grappling with how so much anger can be directed at a sector that claims to keep people healthy.

The killing was horrific and unjustified. The response via social media reflects frustrations that have been building among patient-consumers for decades with a healthcare ecosystem that is increasingly seen as uncaring and unaccountable. The insurance segment has been at the center of this sentiment.

Anger at the healthcare ecosystem is growing. While some of the hostility is specific to the insurance sector, much of it reflects broader frustration with a delivery system that has become increasingly expensive and complex without a corresponding increase in positive health outcomes.

In a survey by NORC at the University of Chicago, “about 7 in 10 adults say denials of health care coverage by insurance companies, or profits made by health insurance companies . . . bear at least ‘a moderate amount’ of responsibility for Thompson’s death.” Alarmingly, according to another study by Emerson College Polling, “41% of voters aged 18-29 find the killer’s actions acceptable.”

Apart from the latest killing, other signs point to the same anger. According to polls, Americans’ rating of the quality of US health care is at its lowest point in the Gallup survey since 2001, when they began tracking the measure.

According to reports from the federal government, healthcare workers are five times more likely to experience workplace violence than workers in other industries, and incidents of violence are on the rise. Hospitals across the country have been forced to dramatically increase the number of security staff and train clinical staff to deal with physical threats.

These are not just isolated incidents. Growing discontent is a response to deep problems with the entire ecosystem.

Faulty incentive structures are one reason anger is building up throughout the system. Insurance companies answer to their shareholders quarterly about their financial prudence, so they have every incentive to ensure they manage utilization, without which insurers believe there would be provider abuse, as some would sought to maximize billing through codification or unnecessary procedures. However, insurance companies make more money the more claims they deny. If patients die as a result of utilization management, whether in the form of seeking step therapy or prior authorization, or denial outright, there is little impact for the insurer.

At the same time, providers operating under a fee-for-service model are incentivized to do more and bill more as they face shrinking reimbursements. This dynamic has led insurers to implement more strategies such as prior authorization hurdles, step therapies, and outright denials—intensifying patient frustration and mistrust.

Until we realign the incentives in the system so that outcomes matter to insurers and health care delivery organizations, the consumer will continue to be the one that hasn’t changed. The structure of contemporary insurance incentives actively encourages risk avoidance and cost reduction rather than any analysis of total economic and clinical value across a continuum of care.

This is exacerbated by the fact that for the average commercial insurance plan, 1 in 5 members disenroll each year, creating little long-term accountability for insurers to invest in patient health outcomes across the lifespan.

Denying coverage for necessary treatments often generates immediate cost savings, while the long-term health consequences—worsening conditions, higher future costs, and avoidable suffering—are external to patients and the broader system.

Another cause of growing confusion and frustration is the lack of transparency throughout the healthcare sector.

As I write in my book Giving value to healthcareit is extremely difficult for consumers to obtain information about cost, quality and outcomes in health care because the necessary information is not readily available. Even after they have undergone a procedure and are looking at the explanation of benefits sent by their insurer, they are not always sure what services they have received, how much those services actually cost, or what if they owe anything.

In a New York Times op-ed published after Brian Thompson’s death, Andrew Witty, chief executive of UnitedHealthcare’s parent company, UnitedHealth Group, agreed as much, saying that “health care is very personal and very complicated, and the reasons for coverage decisions are not well understood.”

The lack of transparency in health insurance has created a system where patients are left in the dark about critical decisions that affect their health and financial well-being. The lack of standardized, easily accessible information on pricing, coverage policies and claims decisions means that consumers cannot make informed choices or effectively challenge denials.

This ambiguity allows insurers to avoid liability while patients face unexpected bills and limited recourse. When buying a car or a home appliance, it’s easy to compare options and get something if we don’t like it. Not so in health care, where plans and processes are shrouded in mystery and we’re more burdened to fix something that shouldn’t have failed the first time. True consumer empowerment requires full visibility and line of sight into cost and quality – without it, the cycle of mistrust will only deepen.

Breaking this cycle requires creating a healthcare model that aligns incentives with patient outcomes. Until patients understand what they are being accused of and why—and know that their doctors and insurers have financial interests aligned with theirs—hostility and frustration will continue to fester.

Clearly this system is broken. The frustration directed at insurers and the broader health care industry is not just about individual incidents, but a reflection of systemic issues: perverse financial incentives that reward the denial of care, a lack of accountability for poor outcomes, and a murky system which leaves patients feeling helpless.

Addressing these challenges requires more than surface-level fixes—it requires a system-wide overhaul that realigns incentives with patient health and transparency at every level.