Maryland has a lot going for it when it comes to health care, including renowned health providers, led by Johns Hopkins Hospital, and a relatively low rate of uninsured residents.

But after an insurance executive was gunned down in New York last week, that didn’t appear to matter. More people seemed to sympathize with the suspect, who grew up in Maryland, or at least his message, than with the slain CEO and his grieving family.

Anti-insurance memes and rants showed up on social media, and someone posted a banner on an Interstate 83 overpass bearing the words inscribed on shell casings found at the scene: “DENY DEFEND DEPOSE,” an apparent reference to rejected insurance claims.

“What we are seeing in these reactions and responses is palpable anger and anxiety about access to affordable health care in the U.S.,” said Marceline White, executive director of Economic Action Maryland, a consumer advocacy group.

She said that the feelings are pervasive even in Maryland, which has passed legislation to expand access to health care, make prescriptions more affordable and further protect people with medical debt. Earlier this year, the General Assembly sought to make it harder for insurers to deny claims.

The steps haven’t solved all the problems. Maryland has long had some of the longest emergency room wait times in the country and has a major shortage of mental health and medical providers. Deductibles are soaring and plenty of people can’t pay their bills.

“Health care,” she said, “still remains out of reach for many.”

Brian Thompson, the CEO of UnitedHealthcare, was fatally shot Dec. 4 outside a New York City hotel. Five days later, Luigi Mangione, a Towson native and scion of a powerful Italian family, was arrested and accused of the killing.

Thompson’s killing brought long-simmering frustrations with the health care system to a new roiling boil.

In an op-ed published Friday morning in the New York Times, Andrew Witty, the CEO of UnitedHealthcare’s parent company, UnitedHealth Group, acknowledged “the health system does not work as well as it should” while speaking out against “the vitriol that has been directed at our colleagues who have been barraged by threats.”

“While the health system is not perfect,” Witty wrote, “every corner of it is filled with people who try to do their best for those they serve.”

But the concerns about costs, denials and administrative hurdles are nothing new and have been ignored for far too long, said Elisabeth Rosenthal, a senior contributing editor at KFF Health News and author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.”

“It’s sad that it takes a horrific event like this to get people paying attention to the frustration and anger that patients have with our health care system,” Rosenthal said.

Mangione may have drawn some inspiration from Rosenthal’s work. A version of the short manifesto that many are citing says “many have illuminated the corruption and greed (e.g.: Rosenthal, Moore), decades ago and the problems simply remain.”

Asked about the apparent reference, Rosenthal said: “Murder is never justified. Our health care system is maddening and frustrating, but that doesn’t justify going out and killing someone.”

She also posted Sunday on X that “I’m not at all surprised at the gloating over an execs tragic murder.”

According to a 2023 survey by KFF, a health policy research and news organization, nearly 6 in 10 insured adults experienced a problem with their health insurance over the last year.

Maryland state Sen. Clarence Lam, who is also a practicing physician in preventive and occupational medicine, said his patients have faced delays in getting medication or seeing specialists because the system is so complex to navigate.

“Not to condone the killing of that individual, obviously, but I think everyone can relate to a health care horror story, and that’s why this story resonates so much to the general public,” Lam said.

Private insurance companies like UnitedHealthcare rank alongside pharmaceutical companies as the least trusted sectors of the health care system, said Mario Macis, an economist at the Johns Hopkins Berman Institute of Bioethics. In a national survey Macis co-authored, private insurers rated lower on trust than the Centers for Disease Control and Prevention, Medicare and Medicaid. Doctors and nurses rated highest.

The reason, Macis said, is the belief that insurers prioritize profits over their clients’ health and well-being.

“This perception that the motivation of insurance companies — and pharmaceutical companies, too ― is making money destroys trust in these institutions,” he said.

Another factor is that requests for coverage are often denied, which contributes to a feeling that “insurance companies are not keeping their promise,” Macis said.

On average, about 16% of in-network claims are denied by health insurers, according to ValuePenguin, a research site dedicated to consumer insurance owned by LendingTree. UnitedHealthcare topped ValuePenguin’s list for the highest denial rate among top insurers at 32%, while Blue Cross Blue Shield, of which Maryland’s largest insurer CareFirst is an affiliate, has a 17% denial rate.

A 2023 survey by KFF found that nearly 1 in 5 insured adults experienced a claim denial in the previous year. Denial rates have increased as companies have used artificial intelligence to automate the review process, according to recent reporting by ProPublica.

Denials occur even when patients take steps to assure that a procedure or medication is covered, often with little explanation for the decision. The steps to contest a denial are often confusing and time-consuming, Rosenthal said.

“Yeah, sure, it’s a high bill, but it’s more the hours they spend trying to get resolution on something that’s wrong, where they’re playing referee between the hospital and the insurer” that becomes “maddening” for patients, she said.

Lam added that denials create “an administrative backlog” for providers, who have to take time away from patient care to fill out extra documentation or make additional phone calls.

“Delays in care are generally not good for patients, and they’re incredibly frustrating for providers,” he said. “The more that you burden them with documentation requirements and paperwork requirements … the more you drive health care providers to do something else and to step back and not see patients — or to retire early.”

Frustrations with the health care system start even before a person signs up for insurance. Without a universal health care system, patients must sort through a maze of different plans, each with its own combinations of premiums, co-pays, deductibles and in-network providers.

“It’s just head-spinning,” Rosenthal said.

Advocates and experts note Maryland has cut its uninsured rate from 14% to 6% since the Affordable Care Act was implemented in 2014, and most people who buy insurance through the state’s health exchange are subsidized.

But for some the premiums remain high, and some don’t see the point in having insurance when they go the year without meeting their deductible, paying mostly out of pocket for care, said Michele Eberle, executive director of the Maryland Health Benefit Exchange.

She said officials and community navigators spend time helping consumers sort plans each year to meet their needs, including “value” plans that cover many services before the deductible is met. Most people, however, still keep the same plan from year to year.

Eberle said consumers with issues can turn to the Maryland Insurance Administration or the attorney general’s Health Education and Advocacy Unit for help dealing with billing problems.

Beth Thomas said patients shouldn’t have to go to such lengths, and in her experience, they don’t always help. The Baltimore woman spent years since she was hit by a bus in 2017 trying to resolve her emergency room bills. She said she was relentlessly hounded to pay when she was legally due charity care.

The experience helped her understand the response to the UnitedHealthcare CEO’s shooting.

“I do not think that murder is the answer. But I also think that both the victim and the guy who killed him could both be considered murderers,” Thomas said.

“Denying care to people in desperate need for the sake of profit for your shareholders may be legal,” she said, “but could also be considered murder by a guy in a suit who gets paid millions of dollars to justify it.”