Sickest Patients Face Insurance Denials Over Prior Authorization

By Lauren Sausser, KFF Health News

Sheldon Ekirch spends a lot of time on hold with her health insurance company.

Sometimes, as the minutes tick by and her frustration mounts, Ekirch, 30, opens a meditation app on her phone. It was recommended by her psychologist to help with the depression associated with a stressful and painful medical disorder.

In 2023, Ekirch was diagnosed with small fiber neuropathy, a condition that makes her limbs and muscles feel as if they’re on fire. Now she takes more than a dozen prescriptions to manage chronic pain and other symptoms, including insomnia.

“I don’t feel like I am the person I was a year and a half ago,” said Ekirch, who was on the cusp of launching her law career, before getting sick. “Like, my body isn’t my own.”

Ekirch said specialists have suggested that a series of infusions made from blood plasma called intravenous immunoglobulin — IVIG, for short — could ease, or potentially eradicate, her near-constant pain.

But Ekirch’s insurance company has repeatedly denied coverage for the treatment, according to documents provided by the patient.

Patients with Ekirch’s condition don’t always respond to IVIG, but she said she deserves to try it, even though it could cost more than $100,000.

“I’m paying a lot of money for health insurance,” said Ekirch, who pays more than $600 a month in premiums. “I don’t understand why they won’t help me, why my life means so little to them.”

SHELDON EKIRCH

For patient advocates and health economists, cases like Ekirch’s illustrate why prior authorization has become such a chronic pain point for patients and doctors. For 50 years, insurers have employed prior authorization, they say, to reduce wasteful health care spending, prevent unnecessary treatment, and guard against potential harm.

The practice differs by insurance company and plan, but the rules often require patients or their doctors to request permission from the patient’s health insurance company before proceeding with a drug, treatment, or medical procedure.

The insurance industry provides little information about how often prior authorization is used. Transparency requirements established by the federal government to shed light on the use of prior authorization by private insurers haven’t been broadly enforced, said Justin Lo, a senior researcher for the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.

Yet it’s widely acknowledged that prior authorization tends to disproportionately impact some of the sickest people who need the most expensive care. And despite bipartisan support to reform the system, as well as recent attempts by health insurance companies to ease the burden for patients and doctors, some tactics have met skepticism.

Some insurers’ efforts to improve prior authorization practices aren’t as helpful as they would seem, said Judson Ivy, CEO of Ensemble Health Partners, a revenue cycle management company.

“When you really dive deep,” he said, these improvements don’t seem to touch the services and procedures, such as CT scans, that get caught up in prior authorization so frequently. “When we started looking into it,” he said, “it was almost a PR stunt.”

The ‘Tipping Point’

When Arman Shahriar’s father was diagnosed with follicular lymphoma in 2023, his father’s oncologist ordered a whole-body PET scan to determine the cancer’s stage. The scan was denied by a company called EviCore by Evernorth, a Cigna subsidiary that makes prior authorization decisions.

Shahriar, an internal medicine resident, said he spent hours on the phone with his father’s insurer, arguing that the latest medical guidelines supported the scan. The imaging request was eventually approved. But his father’s scan was delayed several weeks — and multiple appointments were scheduled, then canceled during the time-consuming process — while the family feared the cancer would continue to spread.

EviCore by Evernorth spokesperson Madeline Ziomek wrote in an emailed statement that incomplete clinical information provided by physicians is a leading cause of such denials. The company is “actively developing new ways to make the submission process simpler and faster for physicians,” Ziomek said.

In the meantime, Shahriar, who often struggles to navigate prior authorization for his patients, accused the confusing system of “artificially creating problems in people’s lives” at the wrong time.

“If families with physicians are struggling through this, how do other people navigate it? And the short answer is, they can’t,” said Shahriar, who wrote about his father’s case in an essay published last year by JAMA Oncology. “We’re kind of reaching a tipping point where we’re realizing, collectively, something needs to be done.”

The fatal shooting of UnitedHealthcare CEO Brian Thompson on a New York City sidewalk in December prompted an outpouring of grief among those who knew him, but it also became a platform for public outrage about the methods insurance companies use to deny treatment.

An Emerson College poll conducted in mid-December found 41% of 18- to 29-year-olds thought the actions of Thompson’s killer were at least somewhat acceptable. In a NORC survey from the University of Chicago conducted in December, two-thirds of respondents indicated that insurance company profits, and their denials for health care coverage, contributed “a great deal/moderate amount” to the killing.

Instagram accounts established in support of Luigi Mangione, the 26-year-old Maryland suspect accused of murder and terrorism, have attracted thousands of followers.

“The past several weeks have further challenged us to even more intensely listen to the public narrative about our industry,” Cigna Group CEO David Cordani said during an earnings call on Jan. 30. Cigna is focused on “making prior authorizations faster and simpler,” he added.

The first Trump administration and the Biden administration put forth policies designed to improve prior authorization for some patients by mandating that insurers set up electronic systems and shortening the time companies may take to issue decisions, among other fixes.

Hundreds of House Democrats and Republicans signed on to co-sponsor a bill last year that would establish new prior authorization rules for Medicare Advantage plans. In January, Republican congressman Jefferson Van Drew of New Jersey introduced a federal bill to abolish the use of prior authorization altogether.

Meanwhile, many states have passed legislation to regulate the use of prior authorization. Some laws require insurers to publish data about prior authorization denials with the intention of making a confusing system more transparent.

Reform bills are under consideration by state legislatures in Hawaii, Montana, and elsewhere. A bill in Virginia approved by the governor March 18 takes effect July 1. Other states, including Texas, have established “gold card” programs that ease prior authorization requirements for some physicians by allowing doctors with a track record of approvals to bypass the rules.

No one from AHIP, an insurance industry lobbying group formerly known as America’s Health Insurance Plans, was available to be interviewed on the record about proposed prior authorization legislation for this article.

But changes wouldn’t guarantee that the most vulnerable patients would be spared from future insurance denials or the complex appeals process set up by insurers. Some doctors and advocates for patients are skeptical that prior authorization can be fixed as long as insurers are accountable to shareholders.

Kindyl Boyer, director of advocacy for the nonprofit Infusion Access Foundation, remains hopeful the system can be improved but likened some efforts to playing “Whac-A-Mole.” Ultimately, insurance companies are “going to find a different way to make more money,” she said.

‘Unified Anger’

In the weeks following Thompson’s killing, UnitedHealthcare was trying to refute an onslaught of what it called “highly inaccurate and grossly misleading information” about its practices when another incident landed the company back in the spotlight.

On Jan. 7, Elisabeth Potter, a breast reconstruction surgeon in Austin, Texas, posted a video on social media criticizing the company for questioning whether one of her patients who had been diagnosed with breast cancer and was undergoing surgery that day needed to be admitted as an inpatient.

The video amassed millions of views.

In the days following her post, UnitedHealthcare hired a high-profile law firm to demand a correction and public apology from Potter. In an interview with KFF Health News, Potter would not discuss details about the dispute, but she stood by what she said in her original video.

“I told the truth,” Potter said.

The facts of the incident remain in dispute. But the level of attention it received online illustrates how frustrated and vocal many people have become about insurance company tactics since Thompson’s killing, said Matthew Zachary, a former cancer patient and the host of “Out of Patients,” a podcast that aims to amplify the experiences of patients.

For years, doctors and patients have taken to social media to shame health insurers into approving treatment. But in recent months, Zachary said, “horror stories” about prior authorization shared widely online have created “unified anger.”

“Most people thought they were alone in the victimization,” Zachary said. “Now they know they’re not.”

Data published in January by KFF found that prior authorization is particularly burdensome for patients covered by Medicare Advantage plans. In 2023, virtually all Medicare Advantage enrollees were covered by plans that required prior authorization, while people enrolled in traditional Medicare were much less likely to encounter it, said Jeannie Fuglesten Biniek, an associate director at KFF’s Program on Medicare Policy.

Furthermore, she said, Medicare Advantage enrollees were more likely to face prior authorization for higher-cost services, including inpatient hospital stays, skilled nursing facility stays, and chemotherapy.

But Neil Parikh, national chief medical officer for medical management at UnitedHealthcare, explained prior authorization rules apply to fewer than 2% of the claims the company pays. He added that “99% of the time” UnitedHealthcare members don’t need prior authorization or requests are approved “very, very quickly.”

Recently, he said, a team at UnitedHealthcare was reviewing a prior authorization request for an orthopedic procedure when they discovered the surgeon planned to operate on the wrong side of the patient’s body. UnitedHealthcare caught the mistake in time, he recounted.

“This is a real-life example of why prior authorization can really help,” Parikh said.

Even so, he said, UnitedHealthcare aims to make the process less burdensome by removing prior authorization requirements for some services, rendering instant decisions for certain requests, and establishing a national gold card program, among other refinements. Cigna also announced changes designed to improve prior authorization in the months since Thompson’s killing.

“Brian was an incredible friend and colleague to many, many of us, and we are deeply saddened by his passing,” Parikh said. “It’s truly a sad occasion.”

The Final Denial

During the summer of 2023, Ekirch was working full time and preparing to take the bar exam when she noticed numbness and tingling in her arms and legs. Eventually, she started experiencing a burning sensation throughout her body.

That fall, a Richmond-area neurologist said her symptoms were consistent with small fiber neuropathy, and, in early 2024, a rheumatologist recommended IVIG to ease her pain. Since then, other specialists, including neurologists at the University of Virginia and Virginia Commonwealth University, have said she may benefit from the same treatment.

There’s no guarantee it will work. A randomized controlled trial published in 2021 found pain levels in patients who received IVIG weren’t significantly different from the placebo group, while an older study found patients responded “remarkably well.”

“It’s hard because I look at my peers from law school and high school — they’re having families, excelling in their career, living their life. And most days I am just struggling, just to get out of bed,” said Ekirch, frustrated that Anthem continues to deny her claim.

In a prepared statement, Kersha Cartwright, a spokesperson for Anthem’s parent company, Elevance Health, said Ekirch’s request for IVIG treatment was denied “because it did not meet the established medical criteria for effectiveness in treating small fiber neuropathy.”

On Feb. 17, her treatment was denied by Anthem for the final time. Ekirch said her patient advocate, a nurse who works for Anthem, suggested she reach out to the drug manufacturer about patient charity programs.

“This is absolutely crazy,” Ekirch said. “This is someone from Anthem telling me to plead with a pharmacy company to give me this drug when Anthem should be covering it.”

Her only hope now lies with the Virginia State Corporation Commission Bureau of Insurance, a state agency that resolves prior authorization disputes between patients and health insurance companies. She found out through a Facebook group for patients with small fiber neuropathy that the Bureau of Insurance has overturned an IVIG denial before. In late March, Ekirch was anxiously waiting to hear the agency’s decision about her case.

“I don’t want to get my hopes up too much, though,” she said. “I feel like this entire process, I’ve been let down by it.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Response to CEO Murder Shows Depth of Frustration with Health Insurers

By Simon Haeder

The U.S. health care system leaves much to be desired.

It is convoluted, fragmented, complex and confusing. Experts have also raised concerns about quality, and disparities are rampant. And, of course, it is excessively costly – far more so than in any other developed nation. Given these failings, it is not surprising that Americans are unhappy with their health care system.

As the public reaction to the killing of UnitedHealthcare CEO Brian Thompson has made clear, however, many Americans are perhaps most unhappy with their health insurers. Indeed, just 31% of Americans have a favorable view of the health insurance industry, according to a 2024 survey.

Yet, given the recent tragic events, as a health policy scholar, I think it would be prudent to take a step back and reflect on the broader health care system and how the U.S. got to this point.

Patchwork Healthcare

Few with any personal experience or professional expertise would describe U.S. health care as the gold standard of health care systems.

For a number of historical and political reasons, it is barely a “system” but rather a complex patchwork with countless different approaches to covering the costs of health care that include splitting the costs between individuals, employers and governments.

Governments also extensively regulate health and health care and, although in a diminished role today, serve as the providers of care through state and county hospitals as well as the Veterans Health Administration.

The result is a regulatory amalgam made up of countless entities. The Affordable Care Act reforms only added additional layers of laws and regulations to an already complex framework.

Yet, even beyond this general structure, Americans face many challenges. Indeed, no other health care system in the world is pricier. This involves costs for medical services but also extremely high administrative costs. Pharmaceuticals are just one example of the excessive financial burden carried by Americans.

For many Americans, these costs are too high, with an estimated 530,000 medical bankruptcies annually.

And despite that high price, concerns persist about quality and access.

In addition, the system tends to be highly inequitable and subject to countless disparities that make it harder for many poorer, rural and nonwhite Americans to access care.

The Role of Insurers

In the United States, insurers play a crucial role in connecting – and at times disconnecting – patients with the care they require.

They are also at the forefront of many of the starkest frustrations that Americans experience – even the ones they are not directly responsible for. While medical providers and pharmaceutical companies charge the world’s highest prices, it is generally up to insurers to tell patients how much they still have to pay or that their care won’t be covered. Insurers are also the ones who determine whether a drug is not covered or a doctor is “out of network,” meaning patients can’t get the specific treatment or care they desire.

To be sure, insurers are not just the messenger – they also add to many of the frustrations patients experience every day. For example, a patient may have to travel very far or wait a long time for an appointment if their provider network is too narrow or simply does not have enough providers. Moreover, the directories and searches that insurers use to show what providers are “in network” may be inaccurate, as they rarely get updated.

For many individuals, this can mean delayed or forgone care, which has major implications for their health and finances. For some, it can even lead to preventable deaths.

Some of the practices insurers are most infamous for, such as rescinding coverage over minor clerical issues and refusing to cover preexisting conditions, ended under the ACA. But some of these issues could return if the incoming Trump administration seeks to undo some of the ACA’s protections.

Even today, so called short-term, limited-duration health plans promise good coverage for lower premiums, but even basic items may not be covered. Many plans, for example, do not cover prescription drugs or even hospital emergency rooms.

Blame the System, Not Just Insurers

Why do insurers act the way they do? For many, the answer may seem simple: to make money. This, of course, rings true – insurers in the U.S. rake in billions of dollar. However, while they tend to be profitable, their margins generally range only from 3% to 5%.

But the story is more complicated than that. With government power limited, insurers are perhaps the only force in the U.S. health care industry trying to rein in rising costs in a health care system where everyone seeks to maximize their profits.

That means insurers take on the role of bad cop, doing things such as limiting access to certain care or doctors. But there are several prudent reasons for doing so; for instance, it’s in the public’s best interest when insurers do not cover drugs that have been shown ineffective or of low quality. And ultimately this does keep premiums lower than they would otherwise be. Of course, insurers and their CEOs profit handsomely in the process. And at times, their methods are ethically and legally questionable.

Ultimately, many if not most of the frustrations Americans experience with health care have their origins in a poorly designed system that is highly inefficient and offers countless opportunities for profit. Yet insurers are only one – perhaps the most visible – part of that broken system.

Simon F. Haeder, PhD, is an Associate Professor of Public Health in the Department of Health Policy & Management in the School of Public Health at Texas A&M University. His most recent work has focused on the implementation of the Affordable Care Act, provider networks, and regulatory policymaking at the Office of Management and Budget.

This article originally appeared in The Conversation and is republished with permission.

Rage Against the System: Opioid Lawsuits, Trump and the UnitedHealthcare Shooting

By Dr. Lynn Webster

In recent years, we’ve witnessed a collective shift in societal attitudes, where deep-seated anger and disillusionment are driving public narratives in unsettling ways.

Three seemingly unrelated phenomena -- the public applause for opioid lawsuit settlements, unwavering support for Donald Trump, and the viral glorification of Luigi Mangione, who allegedly killed the CEO of UnitedHealthcare -- are not as disparate as they first appear.

Together, they reveal a troubling portrait of the undercurrents shaping modern America: a sense of betrayal, unchecked populist rage, and a growing disdain for perceived elites.

The Opioid Crisis

The opioid epidemic has left an indelible scar on American society, and the plethora of lawsuits against pharmaceutical companies like Purdue Pharma, Johnson & Johnson, and others has been widely celebrated.

These legal victories are seen by many as a reckoning for the corporations and individuals who allegedly profited from human suffering. However, beneath this applause lies something darker -- a visceral hatred for systems and figures viewed as complicit in perpetuating a crisis that ruined lives and decimated communities.

While the lawsuits represent an attempt at justice, they have done little to address the underlying anger that millions of Americans feel. Many believe the settlements, while historic, are a drop in the bucket compared to the lives lost and families shattered. This resentment fuels a broader anti-establishment sentiment, one that increasingly targets not only corporations, but anyone perceived to be profiting at the expense of the vulnerable.

The Cult of Trump

Donald Trump’s rise and sustained political influence hinge on a similar anger: a profound distrust of institutions, wokeness, and systems perceived to exploit ordinary Americans.

Trump’s base is galvanized not by policy specifics, but by his ability to channel their rage and direct it at convenient targets -- be it the media, the "deep state," or global corporations. His support thrives on a shared belief that traditional systems, including the government, have failed to protect the American public.

The opioid lawsuits and Trumpism overlap in their shared narrative of betrayal by elites. Whether it’s Big Pharma, corporate executives, or Washington insiders, these movements feed off the same anger -- a belief that the powerful have sacrificed ordinary Americans for profit or political gain.

The Mangione Phenomenon

Enter Luigi Mangione, a name that now reverberates across social media, not because of his actions alone, but because of what he represents in the public imagination.

Allegedly responsible for the murder of UnitedHealthcare CEO Brian Thompson, Mangione has been transformed into a meme and even a symbol of resistance against perceived corporate exploitation. Viral hashtags, merchandise, and online jokes portray him as a folk hero for those who feel victimized by insurance companies and the broader healthcare system.

What’s striking is not just the speed at which this narrative has developed, but the glee with which Mangione’s alleged crime has been embraced. Social media platforms, awash with memes and satirical merchandise, have turned an act of violence into a rallying cry. This reaction is deeply rooted in the same anger that celebrates opioid lawsuits and supports populist leaders.

UnitedHealthcare, representing an industry notorious for denying claims and driving up costs, has become a symbol of the kind of unchecked corporate power people love to hate. Mangione’s alleged actions, while abhorrent, have been reframed as an act of rebellion against a system that many feel prioritizes profits over people.

What This Reveals About Us

Taken together, these phenomena reflect a society grappling with betrayal, powerlessness, and the long-term consequences of institutional failures. The opioid epidemic, insurance company practices, and political stagnation are all symptoms of systems that millions of Americans believe have failed them. Instead of addressing these issues with nuance or systemic reform, we’ve turned to simplified narratives that vilify individuals and institutions.

The memeification of Mangione, much like the unwavering support for Trump and the uncritical celebration of opioid lawsuit settlements, reveals a deep longing for retribution -- a sense that someone, anyone, must pay for the perceived injustices of modern life. Yet this focus on retribution distracts from meaningful solutions and perpetuates a cycle of outrage and despair.

Moving Forward

The overlapping applause for lawsuits, political populism, and dark memes should serve as a wake-up call. These phenomena highlight not only the anger but also the desperation of a society searching for accountability in all the wrong places.

Addressing these issues requires more than legal settlements, political rhetoric, or viral content; it demands a reimagining of the systems and structures that have allowed such disillusionment to fester.

If we fail to address the root causes of this anger -- systemic inequities, lack of accountability, and the growing divide between the powerful and the powerless -- we risk further polarizing a society already on edge.

We need solutions that offer more than fleeting justice or performative outrage. Only then can we begin to rebuild trust in the institutions that are supposed to serve us all.

Lynn R. Webster, MD, is Senior Fellow at the Center for U.S. Policy (CUSP) and Executive VP Dr. Vince Clinical Research. He also consults with the pharmaceutical industry. Lynn is the author of the award-winning book "The Painful Truth" and co-producer of the documentary "It Hurts Until You Die." You can find him on Bluesky: @butchielyons.bsky.social.

CEO Shooting Exposes Deep Faults in U.S. Healthcare System

By Crystal Lindell

Over the last few weeks I’ve been privately lamenting the fact that we just completed an entire presidential election cycle with almost zero mention of health insurance from either of the major party candidates. 

Healthcare costs impact so much of my life and the lives of loved ones, yet it seems like neither the Republicans or Democrats even noticed. Just a few years ago, there were conversations about the possibility of Medicare for All or at least a public option from the U.S. government – but in 2024, both of those things seemed to have been forgotten. 

My credit was destroyed long ago by tens of thousands of dollars in medical debt, all of which were incurred when I was still working full-time and when I still had what most people would consider “good” health insurance. 

Now, as a freelancer, I’ve just gone without. I did try to look into private health insurance, but it costs too much and covers too little, so I decided that it made more sense to live without health insurance for the last 2 years. I pay cash for doctor appointments and prescriptions while trying my best to avoid hospitals.

I’m not the only one I know struggling with health insurance and healthcare costs though. 

My grandma’s Medicare Advantage plan recently kicked her out of a short-term rehab facility because they said she was fit to go home – despite the fact that she could not even stand up to use the toilet yet. 

My sibling had to put off a needed procedure until they could get a new job that offered better insurance. 

And my mom can’t go on Social Security yet because she’s still a couple years too young for Medicare, and the Social Security payments would mean she’d lose her Medicaid eligibility. 

In fact, the only people I’ve ever met in real life who like the health insurance industry are people who work for the health insurance industry. And I have long said that the only people in America who like their own health insurance are the people who’ve never really had to use it

Over the last few years I’ve become even more radicalized on the issue. I’ve come to realize health insurance in America is an active scam. That’s in large part because it’s usually tied to your employment.

The problem is that when someone gets truly sick, one of the first things they often lose is their ability to work. The entire healthcare system is set up to make most people pay for insurance when they’re well, and then to make them lose their insurance as soon as they might need to use it. That’s a scam. Especially as insurers rake in billions of dollars in profit annually while running this scam. 

Plus, if you somehow manage to hold on to your job and your insurance after getting sick, the  insurance companies often won’t pay for all your healthcare costs. They do their best to deny as many claims as possible. 

Vigilante Justice

Last week, UnitedHealthcare CEO Brian Thompson was shot in a targeted assassination in New York. Luigi Mangione, a 26-year-old who suffered from chronic back pain, has been arrested for the crime. 

It was the kind of violent act that just a few years ago I think most Americans would have bristled at. Vigilante violence isn’t usually something that finds mainstream acceptance here. 

But as healthcare costs continue to ruin people’s lives, while politicians ignore all the suffering, the reaction to the shooting wasn’t universal condemnation – it was glee. All over the internet, people rejoiced at the news. And there’s already merchandise supporting the alleged shooter being sold online. 

There’s no doubt that Thompson’s decisions as CEO of the largest private health insurer in the world have resulted in people dying. Afterall, UntiedHealthcare has the highest claim denial rate in the industry. 

And make no mistake, claim denials kill people. It means that patients who needed life-saving treatments couldn’t get them. Yet the U.S. justice system would never make Thompson face any form of criminal liability for those deaths. 

Human beings crave justice though. And when the law stops giving it to them, they seek it elsewhere.

Thompson’s shooting – and the public reaction to it – are predictable. In a system where a well-paid insurance executive will never even be arrested, the desire for justice doesn’t evaporate. 

Most Americans understand this already. We live it everyday, and we know healthcare costs in the United States are unsustainable. 

It’s the politicians – who actually have the power to fix any of this – who refuse to see the truth. They all receive large donations from the insurance industry to make sure we never get so much as a public option. 

But truth demands to be seen. You can’t hide it forever. And people will instinctively feel joy when it is revealed – even if that joy is in response to a vigilante assassination. 

I’m not hopeful that our politicians will acknowledge these truths now. But it would be in their best interest to do so. 

Suspect in Shooting of UnitedHealthcare CEO Had Chronic Back Pain

By Pat Anson

The 26-year-old suspect arrested for last week’s brazen shooting of an insurance company executive suffered from chronic back pain severe enough to require surgery.

Luigi Mangione was detained at a McDonald’s in Altoona, Pennsylvania after a witness reported to police that he looked similar to the man wanted in the Manhattan assassination of Brian Thompson, CEO of UnitedHealthcare. Mangione was initially held on gun charges, and later charged with murder by New York City police.  

"He matches the description of the person we are looking for," NYC mayor Eric Adams said in a news conference.

Mangione had a handgun and a silencer that were "consistent with the weapon used in the murder," according to NYPD Commissioner Jessica Tisch.

He also had several fake IDs and a handwritten manifesto that explained his motives. Police sources told the New York Post that Mangione hated the U.S. healthcare system.

“These parasites had it coming,” the manifesto reportedly says. “It had to be done.”

Mangione is a graduate of the University of Pennsylvania, where he majored in computer science and received a master's degree in engineering.

LUIGI MANGIONE / x

In his online accounts, Mangione wrote about artificial intelligence and reposted links about psychedelics and mental health. He also shared that he suffered from spondylolisthesis, a chronic condition where vertebrae in the spine slip out of place and cause back pain.

Mangione’s profile on Twitter/X includes an x-ray image of several screws embedded in a spine. It appears to be his own x-ray. A second image shows a smiling and seemingly fit Mangione hiking bare-shirted in Hawaii.

A friend and former roommate of Mangione said he had to spend several days in bed after aggravating his back during a surfing lesson in Hawaii.

“He was in bed for about a week. We had to get a different bed for him that was more firm,” R.J. Martin told CNN’s Erin Burnett. “And I know it was really traumatic and difficult. You know, when you're in your early 20’s and you can't do some basic things, it can be really, really difficult.”

Martin said Mangione was thoughtful, friendly and communicated well. The two fell out-of-touch when Mangione left Hawaii, but exchanged texts earlier this year.

“I knew he was going to have a surgery. So earlier this year, I checked in with him. He confirmed that he had had surgery, and he sent me the X rays. It looked heinous with just giant screws going into his spine,” Martin said.

“After that, he called me once and I didn't pick up. We kind of texted a little bit, but we lost contact unfortunately. I feel terrible now. I wish I would have made more of an effort to communicate with him.”

‘Violence Is Necessary to Survive’

While in Hawaii, Martin says Mangione started a book club with his roommates. His profile on Goodreads shows a particular interest in back pain. He listed five books about it, including “Back in Control: A Spine Surgeon's Roadmap Out of Chronic Pain” by Dr. David Hanscom and “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery” by Cathryn Jakobson Ramin.

Ramin wrote about the excessive use of epidural steroid injections, calling them the “bread and butter” treatment of interventional pain doctors.

Hanscom wrote his book to explain why he abandoned his 30-year career as a spine surgeon. He was seeing too many patients being harmed by interventional procedures.

“Modern medicine is ignoring this. We are not only failing to treat chronic pain, but creating it,” Hanscom wrote in a PNN column. “Spine surgeons are throwing random treatments at symptoms without taking the time to know a patient’s whole story.” 

On Goodreads, Mangione reviewed the manifesto of “Unabomber” Theodore Kaczynski, the reclusive hermit who planted bombs that killed three people before being caught in 1996. His words suggest that Mangione saw Kaczynski as a counterculture hero who rebelled against an unjust society.

“He was a violent individual - rightfully imprisoned - who maimed innocent people,” Mangione wrote. “While these actions tend to be characterized as those of a crazy luddite, however, they are more accurately seen as those of an extreme political revolutionary.

'When all other forms of communication fail, violence is necessary to survive. You may not like his methods, but to see things from his perspective, it’s not terrorism, it’s war and revolution.'

It’s not known if Mangione’s back pain became worse after his surgery or what role, if any, United Healthcare had in his treatment.

His friend Martin was shocked by Mangione’s arrest and alleged involvement in murder.

“I can make zero sense of it. You know, there's never justification for violence. We live in a democratic system with processes and procedures to address our issues. I can make no sense of it,” he said.

If Mangione did resort to violence against the healthcare system, he wouldn’t be the first patient to do so. In recent years, doctors in Indiana, Nevada and Oklahoma have been shot by disgruntled pain patients or their spouses.