Before shooting, Brian Thompson worried about UnitedHealth’s negative image

In early 2024, UnitedHealthcare CEO Brian Thompson had an urgent warning for his colleagues: The company has a public relations problem.

Average Americans didn’t understand the massive insurance company’s role in the nation’s health system, Thompson argued in internal discussions and with fellow executives, including steps it had taken to eliminate out-of-pocket costs for lifesaving drugs, colleagues said. Instead, UnitedHealthcare and its parent, UnitedHealth Group, faced investigations, a congressional probe and simmering consumer anger over charges it was making billions by denying health care to the ill and elderly.

“He understood that the public was frustrated with what they perceived the company’s actions to be,” according to one of the people who spoke with Thompson. “He was actively articulating a vision that helped better educate and help people better understand what the company is doing.”

Anger directed at the company played a role on Dec. 4, authorities said, when 26-year-old Ivy League graduate Luigi Mangione allegedly gunned down the executive in Midtown Manhattan as Thompson was on his way into UnitedHealth’s annual investor conference. Police have said Mangione was motivated by animus toward America’s health care system and appeared to have singled out Thompson because of UnitedHealth’s sheer size.

As the murder investigation unfolded, the popular animosity that Thompson had warned against fueled a cruel backlash online. Mangione was hailed as a folk hero. Sympathy for Thompson and his surviving wife and children was “out of network,” people wrote. Anti-CEO “Wanted” posters surfaced across New York City with Thompson’s face slashed with a big red X.

Horrified colleagues and friends say the online caricature bears no resemblance to the man they knew — a well-liked executive who had bootstrapped his way from his family’s small farm outside Jewell, Iowa to the highest echelons of the business world. Many spoke to The Washington Post on the condition of anonymity to freely discuss their memories of Thompson and private conversations with him.

The two men whose lives allegedly collided on the dark Manhattan street on Dec. 4 — shooter and victim — took strikingly different paths to get there. Despite railing against big business, Mangione came from a wealthy Maryland family that owned luxury golf courses and nursing homes; he attended a tony private boys school. Thompson went to a small public high school and had plunked golf balls on a nine-hole course in the shadow of his town’s grain elevator.

“I try not to draw too many distinctions between work and life and maybe that’s growing up on a farm in Iowa,” Thompson told fellow employees this year, according to material shared by UnitedHealth Group. “I didn’t grow up in a setting where these things were separate.”

He grew up the younger of two sons of a small farmer who worked at the community’s grain elevator. He spent his summers fishing at the local lake and “walking beans” — a prairie farm term for weeding soybean fields, friends from Jewell said. He excelled at academics at South Hamilton High School, where he was both valedictorian and homecoming king, according to Todd Coy, a former health and physical education instructor and now principal.

“He was definitely a perfectionist,” Coy said. “It wasn’t good enough to get an “A” on a test. He wanted to know why he missed a question, could that question have been worded differently. He pushed himself so very much.”

Thompson continued to excel academically at the University of Iowa, where he graduated with a bachelor’s degree in business administration with an accounting major in May 1997, with special honors. He worked for a time at PricewaterhouseCoopers before landing a job at Minnesota-based United HeathGroup in 2004.

As he rose quickly through the ranks of America’s largest health care corporation, Thompson found opportunities to shape the nation’s health system — including at an urgent moment during the coronavirus pandemic, associates said.

Congress set aside billions of dollars in emergency payments for health care organizations that were suddenly struggling to meet payroll amid the national shutdown in March 2020. But federal officials could not find a partner that could get the money to organizations that desperately needed it. Thompson told federal officials that his massive company’s banking arm could rush emergency funds to hospitals and other providers — and said it could be done within a week.

“In the face of so many people saying this can’t be done, honestly Brian was the guy who made it happen,” said Stephen Parente, a finance professor at the University of Minnesota and former Trump administration health official who worked with Thompson during that time.

More than $135 billion would eventually be distributed through the UnitedHealth-backed fund, which was credited with keeping thousands of hospitals and other health care providers afloat during the pandemic.

One year after engineering the payments, Thompson would be elevated to the top job at UnitedHealthcare — the nation’s largest health insurer, which provides coverage to about 50 million Americans. He would make “consumerism” his focus, colleagues have said, often invoking the need for the sprawling insurer to focus on individual patients.

“We know that millions of our members experience complex health issues each year, throughout the year,” Thompson said in November 2022 public remarks. “We can help carry the burden.”

Colleagues said that is the Thompson they remember, with several weeping in recent interviews as they discussed his work and life.

Patient advocacy groups have taken a dimmer view of his tenure, saying that UnitedHealthcare denied too many requests for care under Thompson’s watch. He was among the highest-paid executives at UnitedHealth Group, with a compensation package last year valued at $10.2 million.

“We’ve been working for two years on the issue of care denials, and the research shows that almost every family in the U.S. will experience the outrage of having a doctor prescribe a treatment only to have an insurance company like UnitedHealthcare get in the way,” Sulma Arias, executive director of People’s Action Institute, said in a statement last week.

UnitedHealth has defended its track record in handling medical claims and said “misinformation” has been circulating about how often it denies care.

The company’s insurance division pays about 90% of medical claims when they’re submitted, according to a statement from the company late Friday. Of the remainder that undergo additional review, only 0.5% are “due to medical or clinical reasons,” UnitedHealth said.

Allies of Thompson say that while they understand the scrutiny of UnitedHealth, the complexities of the health system should not be laid entirely at the company’s feet. Many of the price hikes that consumers blame on their insurance companies can be traced back to hospitals and doctors raising their own prices, which are then passed along to patients.

“Together with employers, governments and others who pay for care, we need to improve how we explain what insurance covers and how decisions are made,” Andrew Witty, the CEO of UnitedHeath, wrote in a New York Times op-ed on Friday. The piece encapsulates what Thompson was privately arguing, the people who spoke with him said.

Despite Thompson’s high-powered role, he often took a back seat to Witty in public and did not seek out media attention, colleagues said. Inside the company, Thompson was known to drop f-bombs and had a habit of constantly chewing gum — a casual, unassuming style that helped him to bond with employees throughout its ranks.

“His small-town Iowa upbringing enabled him to be particularly effective intersecting with everyone,” a former colleague said. “He was the most unpretentious guy in the world.”

Pressures on UnitedHealthcare mounted in recent months. The company and others were found to have high rates of prior authorization denials for patients in Medicaid managed care plans, according to a report last year by the inspector general’s office at the Department of Health and Human Services. A Senate report released in October faulted UnitedHealthcare and other insurers for repeatedly turning down Medicare Advantage patients’ requests. And Thompson himself had been accused of insider trading in a lawsuit.

There were some signs of stress in his personal life. In 2017, he was arrested and convicted of driving while impaired, ultimately sentenced to probation. In 2018, he purchased a home not far from his wife and two boys and began living separately, neighbors said.

“Brian was a wonderful person with a big heart and who lived life to the fullest,” his wife, Paulette, a physical therapist, had said in a statement to the Minnesota Star Tribune. “He will be greatly missed by everybody. Our hearts are broken, and we are completely devastated by this news. He touched so many lives.”

Throughout, he was a “really engaged dad” with his two sons, the colleague said, going to Timberwolves games with his eldest son, about to head off to college, and in the bleachers at their own games.

“It was really important for him to know that they could look up and see their dad,” he said.

Back in Jewell, the tiny town of about 1,100 is still reeling from the death of their favorite son — and the caricature of a villain that has emerged online. His father, Dennis, died last year and his mother, Pat, still cuts hair in town, friends said. The family declined requests for comment.

“I can tell you when he was in this community, he was taught right from wrong,” said Rick Young, a Hamilton County Supervisor and longtime friend of the family. “What happens after that, we have no control over. When you get to that level, you’re going to have to make tough decisions and you’re going to make enemies. That’s part of the world and of life.”

Thompson was remembered in a private ceremony this past week in Minnesota, according to news reports. Folks in Jewell would have liked to hold some kind of memorial as well, Young said, but the pressure of the national media scrutiny was too intense.

Aaron Schaffer contributed to this report.