--:-- Sean Rameswaram: On Wednesday of last week, a man was shot in the United States, but this was not your average shooting. Almost immediately, people were celebrating his death, and not just the people you'd expect.
--:-- Sean Rameswaram: There were moms on Facebook making jokes about it. There were several of those horny copypasta text messages circulating around. There was a UnitedHealthcare shooter lookalike contest over the weekend in Manhattan. At least one person got a tattoo of the suspect.
--:-- Sean Rameswaram: On Monday, Luigi Mangione got arrested, and then things really got nuts. He went from a few dozen Twitter followers to 300,000 overnight. People are thirsting for his six-pack. Luigi Mangione is a brat.
--:-- Sean Rameswaram: The McDonald's where he was arrested has been review-bombed. People are saying there are rats behind the counter. People are saying Popeye's employees would have helped him get rid of the gun. Someone's got some explaining to do, and it's us. It's Today Explained.
--:-- Sean Rameswaram: Support for Today Explained comes from BetterHelp. Let me tell you a true story. Last weekend, I got an email from a listener who wanted to discuss their problems with me. And I said, look, I don't think that this is about me personally. At least I hope it's not.
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--:-- Sean Rameswaram: Today Explained, Sean Ramos for I'm here with Brittany Krigstein from Gothamist at WNYC in New York. She's been covering the shooting since pretty much the second it happened.
--:-- Brittany Krigstein: From the second it happened, the second we got a notification about somebody being shot in Midtown, Of course, we were on high alert because I cover gun violence consistently across the entire city.
--:-- Brittany Krigstein: People don't often get shot in Midtown. The precinct where this happened has not had a shooting at all this year. We pretty quickly got video footage of the shooting, of this execution.
--:-- Brittany Krigstein: What did that video footage reveal? So the video basically shows a masked man in a hoodie, really hard to make out who it could be, who just very calmly waits and then fires several shots within close range of, now we know is Brian Thompson, who sort of appears in the video startled.
--:-- Brittany Krigstein: He stumbles away. He was hit, officials said, in the calf and also in the back. And so he did have a second to sort of turn around and face a shooter who calmly seemed to clear a jam in his gun and continue firing.
--:-- Brittany Krigstein: There was a bystander right there when it all happened who ran away, but the shooter wasn't interested in that person. They were going for Thompson. The shooter escaped through a nearby alleyway.
--:-- Brittany Krigstein: Again, this is Midtown Manhattan, but at 6:45 in the morning, there weren't too many people around. He runs through this alleyway, according to officials. He then jumps on an e-bike and starts pedaling north to Central Park, and that's basically the last place he was seen for some time.
--:-- Brittany Krigstein: We know he ditched his backpack there, which officials later found and found that it only contained some Monopoly money. And then he apparently jumped in a taxi.
--:-- Brittany Krigstein: He was caught on surveillance video heading uptown even further to the Port Authority bus station on 179th Street and Broadway, and officials basically lost track of him after that from what we know of the investigation.
--:-- Brittany Krigstein: And we saw footage of, you know, the NYPD searching Central Park, and people didn't seem very impressed with that footage. A lot of people were mocking the NYPD over the weekend.
--:-- Sean Rameswaram: Guys, I have not stopped laughing all morning about the backpack in Central Park. He left it for them to find on purpose. And they're so bad at their jobs that it still took them days to find it.
--:-- Brittany Krigstein: All right, look, it's been five days. You guys really don't have anything? We've tried it all, sir. We even put our Patagonias on in Central Park and put our hands through the bushes a little bit.
--:-- Sean Rameswaram: Was anything holding this search up? Well, it's really hard to say. Obviously, with the vastness of Manhattan and the feeling that this person could have gone anywhere, not just Manhattan, in all of New York City.
--:-- Brittany Krigstein: Now, as somebody who covers gun violence day in and day out in New York City, I can confirm that it usually does take a couple of days to find people, even when the cases are pretty cut and dry, even when police say that they know exactly who they're looking for.
--:-- Brittany Krigstein: Surveillance video canvassing takes a long time. This person obviously did as well as he could to shield himself, hide his face. We have that one picture of him smiling in the hostel that really sort of seemed to accelerate the investigation because it was a really good picture of his face.
--:-- Brittany Krigstein: But other than that, police didn't have a ton to go on. Of course, DNA evidence takes a long time. They say he discarded a cup at Starbucks. These things all take time.
--:-- Sean Rameswaram: This was just a bystander, a local person, an employee at a McDonald's in Pennsylvania. Yeah, tell us about what happened there. How was the shooter finally caught?
--:-- Brittany Krigstein: Earlier this morning in Altoona, Pennsylvania, members of the Altoona Police Department arrested Luigi Mangione, a 26-year-old male, on firearms charges.
--:-- Brittany Krigstein: So apparently he was sitting and eating at this McDonald's in Altoona, Pennsylvania. That's about 230-some-odd miles away from New York City. And he was there typing away on a laptop wearing a beanie and a medical mask.
--:-- Brittany Krigstein: And an employee recognized him based on the photos that police had circulated, now photos that seemingly have gone around the country and back again. And this person called the local authorities who came.
--:-- Brittany Krigstein: Responding officers questioned the suspect who was acting suspiciously and was carrying multiple fraudulent IDs as well as a U.S. passport. When they asked him about whether he'd been in New York City, he actually went silent and started shaking, according to court documents.
--:-- Sean Rameswaram: And that was pretty significant to them that, you know, he had something to hide. They took him in for questioning. They found a 3D printed ghost gun, which was consistent with the gun that was used to shoot Thompson.
--:-- Sean Rameswaram: Additionally, officers recovered a handwritten document that speaks to both his motivation and mindset. What do we know about a possible motive here, Brittany?
--:-- Brittany Krigstein: There is a lot to pull from. Obviously, with the with the amount of attention this case has generated, the social media spheres are just exploding with different kinds of theories.
--:-- Brittany Krigstein: One interesting thing about Mangione is that he did have pretty open and exposed social media accounts in a lot of the cases where you have somebody who plans to do something like this, they lock down their social media, they don't want anybody knowing anything about their lives.
--:-- Brittany Krigstein: He almost seems to have been in the opposite mentality. There are photos he posted of an X-ray of what appears to be his own back with some pretty serious-looking pins in it.
--:-- Brittany Krigstein: And it's been reported by several outlets and talking to his family members and old friends that he had a pretty serious back surgery maybe a few months ago. And after that sort of fell off the face of the earth, people say it drove him crazy.
--:-- Sean Rameswaram: We don't exactly know what his interaction was with UnitedHealthcare at this time. We don't know exactly what was written in that manifesto besides ill will towards corporate America. That's what police have shared with us so far.
--:-- Brittany Krigstein: So again, there's just a lot of speculation going on, but he comes from a very well-connected family in Maryland. He went to a really good prep school. He graduated the University of Pennsylvania. He was high school valedictorian.
--:-- Sean Rameswaram: So in Pennsylvania, he's been charged with gun possession. And in New York, charges dropped late Monday night from the Manhattan DA's office charging him with murder in the second degree, which is basically just murder with intent to kill somebody.
--:-- Sean Rameswaram: Three counts of gun possession and also possession of a forged instrument, which could relate to those fake IDs. And he will be extradited at some point. It's hard to say exactly when.
--:-- Sean Rameswaram: In the days before this killer was caught, there were corners of this country where he was a folk hero fighting for the poor, the disadvantaged, against this health care behemoth. But then they catch this guy and it turns out he's like this Ivy League, you know, scion from Maryland who's got like all sorts of money and means.
--:-- Sean Rameswaram: Does that sort of flip the narrative a little bit? I think it could. People are just trying to digest, like I said, what was that connection? Why did he jump from this upbringing? Maybe it would make more sense if he, you know, was poor and disadvantaged and was struggling to afford basic medical care for his family.
--:-- Sean Rameswaram: But it just doesn't seem like that was necessarily the case, given his upbringing, given his education. I will just say I cover murders for a living. I have never seen, and I've covered murders of people who are very unpopular.
--:-- Sean Rameswaram: I have never seen such glorification of somebody who has allegedly committed a violent act against somebody else. Jokes aside, memes aside, people have been sharing their own struggles with health insurance and deep struggles, surgeries, illnesses.
--:-- Sean Rameswaram: And they're using this incident as a platform to really express a lot of those pent-up feelings. And that has been a real moment of reckoning, I think, across the country about the systems that we have here for taking care of ourselves and each other.
--:-- Sean Rameswaram: And it just goes to show that no matter what social status you're from, somebody with money, with means, with education had a real serious problem seemingly with health insurance.
--:-- Sean Rameswaram: So in that sense, it's been a strange uniting force, whether or not you agree with a lot of the things being said. It's just been a real reckoning with the health insurance system and people are hoping something will change.
--:-- Sean Rameswaram: Brittany Krigstein covers crime for Gothamist and WNYC Gothamist.com. When we're back on Today Explained, we're going to talk about UnitedHealthcare and why so many people hate them.
--:-- Sean Rameswaram: Support for Today Explained comes from Built Rewards. These days, it seems like everybody has a rewards program. You swipe your card and you get one cent on the hundred dollars. But with your rent frequently you just pay month after month You never get anything from it other than that roof over your head Not anymore says Built Rewards.
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--:-- Sean Rameswaram: Support for the show today comes from LifeKit, the podcast from NPR. What's in your life kit? I'm asking. They didn't ask that.
--:-- Sean Rameswaram: Every day you have to make choices that might shape the direction of your life, but you can't flip to the back of the book to find an answer key. Instead, you can listen to the LifeKit podcast from NPR.
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--:-- Sean Rameswaram: Enough from me. Go listen to the show Life Kit. It's a podcast from NPR. You're listening to Today Explained. My name is Bob Herman. I'm a reporter at Stat News.
--:-- Bob Herman: I cover the business of healthcare. So hospitals, health insurance, all types of providers, anything where the money flows in healthcare.
--:-- Sean Rameswaram: We reached out to Bob because Bob knows UnitedHealthcare. UnitedHealthcare is just one part of this massive company called UnitedHealthGroup.
--:-- Bob Herman: And we've had a whole series this year called Healthcare's Colossus that's looked at this massive company, kind of how it has its tentacles everywhere.
--:-- Bob Herman: A lot of people recognize it for UnitedHealthcare, this insurance company. It's just, you know, everyone hates an insurance company. But people don't recognize all the other components that it owns.
--:-- Bob Herman: It owns a ton of medical practices. It either employs or is affiliated with one out of every 10 doctors in the country. And I don't think everybody fully recognizes just how large and involved this company is outside of health insurance.
--:-- Sean Rameswaram: It is not just a health insurance company. That's what it's most known for. That's why it's often reviled. But it is everywhere else.
--:-- Sean Rameswaram: And I think people need to recognize, especially on the medical group side, the physician side, they play a major role there. Almost immediately, people were celebrating this homicide.
--:-- Bob Herman: What was your reaction to that? Yeah, the reactions were pretty morbid, pretty grim. You know, the dancing on the death of somebody was just pretty vile.
--:-- Bob Herman: But anyone who covers healthcare 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 it's just persisted since then.
--:-- Sean Rameswaram: So people's frustrations have been bubbling under the surface for so long so to say you were surprised by all the reactions, then I think maybe you had your head buried in the sand a little bit.
--:-- Bob Herman: We asked you here, Bob, to better understand why people would be so mad at UnitedHealthcare specifically.
--:-- Sean Rameswaram: So before we talk about what this company does that might upset people, can you just tell us about the company generally?
--:-- Bob Herman: So UnitedHealthcare is the largest health insurance company in America. They cover more people than anyone. That includes Medicare Advantage, Medicaid, Obamacare, and all the different types of employer plans out there. And there's a lot.
--:-- Sean Rameswaram: Which I imagine makes them pretty powerful in this market. Yeah. Now, a lot of healthcare dynamics are local. You know, the fights that often occur between health insurers and providers like hospitals and doctors, it's all about who has market share in a specific area.
--:-- Bob Herman: So United might not always have the biggest market share in a given area, but nationally, they are very powerful. They are very profitable. There's no way getting around them in pretty much any market. They exist almost everywhere in some capacity.
--:-- Sean Rameswaram: And what do they do with that power? How do they throw it around? If you have a UnitedHealthcare plan, you want them to negotiate better rates for you. That's their primary function.
--:-- Bob Herman: And so they use some of that have to try and drive better deals with hospitals and doctors and other types of facilities. They're also an insurance company and they happen to deny or delay claims as well.
--:-- Sean Rameswaram: As an insurance company, the easiest way to make money is to make sure you're paying out fewer dollars. Now, there are laws in place, especially a federal law that says, you know, you have to spend a certain amount of your premium dollars on care for people.
--:-- Bob Herman: You just have to do it. But insurers have an incentive to stay as close to those thresholds as possible. They don't want to have to pay out more than they absolutely have to.
--:-- Sean Rameswaram: You just, of course, used one of the operative words in this story because as we found out, the shooter had inscribed three words on his bullets. deny and then also defend and depose.
--:-- Bob Herman: Is this company known for its denials? I think every health insurance company out there is known for their denials to some degree. Specific rates of denials are tough to come by.
--:-- Bob Herman: But insurers, especially the for-profit ones that sell on the stock market, they have an incentive to deny care. You know, there have been so many issues with denials over the years.
--:-- Sean Rameswaram: And my colleague Casey Ross and I reported on a big one within Medicare Advantage. And that's the program for older adults. And UnitedHealthcare is the biggest in Medicare Advantage.
--:-- Bob Herman: And over the past several years, they've been using algorithmic prediction, predictive tools and artificial intelligence to basically ramp up denials specifically in post-acute care.
--:-- Sean Rameswaram: And that's 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 Rameswaram: What exactly does that mean, Bob, that they're using algorithms and AI to deny Medicare Advantage? How do they do that?
--:-- Bob Herman: Yeah, so let's say someone goes to the hospital and then the hospital says, okay, you're ready for physical therapy, occupational therapy, speech therapy. Let's send you to a rehab facility, a nursing home.
--:-- Bob Herman: So a person will go there and they'll start their physical therapy. And behind the scenes, UnitedHealthcare has used a tool called NaviHealth, and there's an algorithm within the company that basically looks at the patient's demographics, how sick they are, their history, and tries to come up with some kind of prediction of how much time they'll need in that nursing home.
--:-- Bob Herman: Let's say it's 16 days. That's what the algorithm says. After 16 days, you should be good. Now, if it's used as a guide, that's fine. But in many cases, I mean, we found documents that said that, you know, United told their case managers, you have to stick to the algorithm.
--:-- Sean Rameswaram: And that's where it becomes a problem. Because if you're saying this algorithm spits out 16 days for somebody and they're not ready to go home on the 16th day, if they can't even go to the bathroom themselves, if they still can't walk around.
--:-- Bob Herman: But the algorithm says time to ship them out. That's where it's a problem. And that's what's happened. And then families are left with a 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?
--:-- Sean Rameswaram: 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 that's how the algorithms play in those types of situations.
--:-- Bob Herman: And people know this is happening and they're mad about it. On the Medicare Advantage side, most people actually don't. They're not aware as much on this because the algorithm happens behind the scenes.
--:-- Sean Rameswaram: It's not like families are getting a sheet of paper saying, hey, our algorithm says you have this much time here. They really don't find out about this until the nursing home says, hey, your insurance is up and we have to kick you out.
--:-- Sean Rameswaram: Now, the denials are very front and center in other insurance plans where they say like, oh, I need this back surgery or I need this prescription. And then United will come along with maybe a prior authorization, which just says, hey, doctor, fill out more paperwork to make sure that this person needs this procedure and needs this drug.
--:-- Sean Rameswaram: And then maybe they'll come back with a denial then that says, we're not going to cover this procedure or this prescription drug. That's where it's most front and center for people.
--:-- Sean Rameswaram: That's where I think a lot of the outrage comes from. There's just those widespread kind of delays and denials there. And anyone can appeal any denial but it is such an arduous process if you're sick or injured that's not something you want to be doing and you might not have family to help you out either.
--:-- Sean Rameswaram: So it is very clearly a problem. And is this like a UnitedHealthcare problem or is this a systemic problem? It feels like a systemic problem.
--:-- Bob Herman: So does UnitedHealthcare get an inordinate amount of heat just because it's the biggest? Yeah, I think that's right. This is systemic. This is not isolated to just UnitedHealthcare.
--:-- Sean Rameswaram: UnitedHealthcare gets the most criticism and heat for this because they are the largest. I mean, they're just a very common provider for any workplace plan.
--:-- Bob Herman: But I mean, there are other large insurers. This is this, you know, very common thing, Cigna, Aetna, all the Blue Cross Blue Shield plans, Humana.
--:-- Sean Rameswaram: This is just how U.S. health insurance works. This is a systemic issue. This is, especially for the insurance companies that they're on the stock market, they have a duty to make money for shareholders.
--:-- Bob Herman: And one of the ways that they do that is by making sure that they pay out fewer claims. It's just part of it. The most watched number in every earnings call for an insurer is called the medical loss ratio.
--:-- Sean Rameswaram: That's a number that says this is how much money of our premiums that we spend on medical care. And lower is better. If it's higher than expected, Wall Street freaks out.
--:-- Sean Rameswaram: So I think that kind of tells you a lot. You can read Bob Herman at statnews.com.
--:-- Sean Rameswaram: Miles Bryan and Hadi Mawajdeh produced our show today with help from Peter Balanon-Rosen. They were edited by Matthew Collette and fact-checked by Laura Bullard and mixed by Rob Byers and Patrick Boyd.
--:-- Sean Rameswaram: This is Today Explained. Thank you. Support for the show comes from Mercury. What if banking did more? Because to you, it's more than an invoice. It's your hard work becoming revenue. It's more than a wire. It's payroll for your team. It's more than a deposit. It's landing your fundraise.
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