Luigi Mangione’s Manifesto Is Stupid

Luigi Mangione reportedly will plead not guilty to the murder of UnitedHealthcare Chief Executive Officer Brian Thompson. Still, the written statement found in his backpack—published in full by freelance journalist Ken Klippenstein and quoted in part by other mainstream media outlets—is an apparent confession and rationalization.

The assassination was a terrorist attack designed to spread terror among health insurance executives and force changes in behavior. Mangione wrote, “These parasites simply had it coming” because they “have simply gotten too powerful, and they continue to abuse our country for immense profit.” The words “delay” and “deny” were scrawled on the fatal bullet casings, drawing attention to the role the insurance industry plays in determining coverage for treatments—be it motivated by profit or interest in avoiding unnecessary procedures—often to the frustration of doctors and patients.

Such vilification may endear Mangione to those who have grotesquely cheered the murder and the murderer on social media. But what the 262-word statement reveals is how oversimplified issue analysis mixed with extreme self-righteousness can lead to fatal violence. If Mangione’s theories were just the rantings of a deranged young man, it wouldn’t be worth engaging them. But they represent a line of thinking that private health insurance accounts for America’s poor public health when, in fact, the culprits are many, from food policy to culture to illegal drugs to other actors in the health care space.

The substantive nut of Mangione’s argument is:

…the US has the #1 most expensive healthcare system in the world, yet we rank roughly #42 in life expectancy. United is the [indecipherable] largest company in the US by market cap, behind only Apple, Google, Walmart. [Fact check: it’s actually the 15th largest.] It has grown and grown, but as [sic] our life expectancy? No the reality is, these [indecipherable] have simply gotten too powerful, and they continue to abuse our country for immense profit because the American public has allwed [sic] them to get away with it.

The discrepancy between what the United States spends on health care and where it ranks in life expectancy is glaring, but it was not always thus. In 1980, according to the Peterson-KFF Health System Tracker, American life expectancy was only 0.8 years less than the average of “comparable countries.” By 1995, the gap was two years, and by 2013, three years. In 2019, it was just under four years. During this four-decade period, American life expectancy increased by 5.5 years to reach 78.8 (largely stagnating in the 2010s), while it increased by about 8 years in the comparable countries.

When the Covid-19 pandemic hit in 2020, the gap widened to five years, as American life expectancy sharply dropped by nearly two years. Another dip in 2021 made the gap 5.8 years, but the United States partially rebounded in 2022—the last year of Tracker data—with a life expectancy of 77.5, trailing the other countries by 4.7 years and about a year-and-a-half lower than its peak in 2014.

But how are lagging life expectancy gains in America over the last 44 years primarily the fault of UnitedHealthcare, let alone the person who served as its CEO since 2021?

A 2021 study produced by the National Academies of Science, Engineering, and Medicine found that the “four largest contributors to the growth in the U.S.–peer country mortality gap between 2000 and 2015 were circulatory diseases, diseases of the digestive system, accidental poisonings, and intentional self-harm (i.e., suicide).” (Note that more than half of suicides in America are from guns, which are more readily available in America than most other countries.) The study also observed that “among males, mortality due to diseases of the digestive system, mental health or alcohol use, and assault (i.e., homicide) stagnated over the period in the United States but continued to decline in the peer countries.”

A 2023 article exploring American life expectancy for the American Journal of Public Health by Steven H. Woolf, a medical doctor and professor of family medicine and population health at Virginia Commonwealth University, while stopping short of drawing definitive conclusions, offered, “Potential contributors included not only downstream, proximal factors such as obesity, substance abuse, and deficiencies in the US health care system but also upstream, macrostructural factors such as US policies. For example, countries with better health outcomes typically offer more generous social welfare and income support programs and enforce stronger regulations to protect public health and safety.”

Woolf also identified geographic discrepancies within the United States, with the Midwest accounting for “more than half of US states that experienced a decline in life expectancy in 2010 to 2019.” He noted:

…the increase in midlife mortality that followed 2010—much of it driven by drug overdoses, suicide, and liver disease—was disproportionately concentrated in the Industrial Midwest. States in the Rust Belt and agricultural heartland endured the collapse of the manufacturing sector and the farm crisis, which claimed jobs and family farms, increased economic precarity, and potentially compromised health outcomes. These states also underwent a political shift to more conservative policies on matters that affect health (e.g., Medicaid eligibility, tobacco taxes, social welfare). Studies show that states that adopted more conservative policies were more likely to experience stagnant or decreasing life expectancy and higher mortality even after adjustment for confounding variables.

A companion article in the same journal further highlighted how the pandemic and the spike in opioid use worsened these underlying issues in recent years, “the US life expectancy disadvantage is attributable to multilevel, multifactorial causation, which increases the challenges of identifying all of its drivers. However, this causal web also explains why the life expectancy disadvantage has been robust for decades and is exacerbated in the context of new risks (e.g., opioids, COVID-19 pandemic) and perhaps even self-perpetuates. Indeed, premature deaths devastate families and communities, likely causing new trauma, which poses new health risks.”

Much of what explains America’s unimpressive life expectancy—socioeconomic inequalities, substance abuse, gun violence, obesity, poor initial pandemic response—has nothing to do with the gatekeeper role played by insurance companies when determining coverage for treatments. And nowhere in these academic studies do we find researchers fingering the practices of insurance companies.

Mangione himself appeared to have some grasp of that, maddeningly so. He wrote, “Obviously the problem is more complex, but I do not have space, and frankly I do not pretend to be the most qualified person to lay out the full argument.”

Never have I read a bigger copout.

He had nothing but space; confessions don’t have word count limits. And apparently, he knew he wasn’t qualified to lay out a comprehensive critique of the American health care system. Yet, he deemed himself competent enough to address the complex problem through a simple murder. Moreover, he christened himself “the first to face it with such brutal honesty.” This is not intellectual consistency. This is psychopathic mansplaining with deadly consequences.

Let’s not play the I-don’t-agree-with-violence-but game. There’s no gain to be had by claiming Mangione may not have used the proper method and or made the best argument, but at least he shone a light on a significant problem. That’s parallel to the logic JD Vance used when defending his lies about Haitian migrants in Springfield, Ohio, eating pets: “If I have to create stories so that the American media actually pays attention to the suffering of the American people, then that’s what I’m going to do.” Not only did Vance’s lies lead to bomb threats and school closures, but they also mischaracterized the situation in Springfield and scapegoated Haitians for problems they didn’t cause. Mangione’s mischaracterization led to an even worse outcome.

Mangione did not mention any particular practice of UnitedHealthcare, and I’m not in a position to defend any specific practice of UnitedHealthcare. But I do know UnitedHealthcare, or any one health insurer, did not cause America’s life expectancy problem. And insurers won’t be able to solve the problem independently of broader public policy reforms.

The answers to these difficult questions will come from public policy experts. Not murderers.

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