Luigi Mangione, the suspected shooter, is led from the Blair County Courthouse following an extradition hearing on December 10, 2024, in Hollidaysburg, Pennsylvania. A note found on him at the time of his arrest reveals a man seemingly radicalized by statistics. He wrote, “The US has the #1 most expensive health care 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. It has grown and grown, but [h]as our life expectancy?” Mangione, the alleged killer of Brian Thompson, CEO of UnitedHealthcare, is from a wealthy and influential Maryland real estate family. He had recently withdrawn from friends and family after experiencing severe medical issues.
Mangione’s assertions, while broadly stated, hold a degree of accuracy. The United Nations’ data places the U.S. life expectancy somewhere in the 60s among world countries, between Panama and Estonia. Within the Organization for Economic Cooperation and Development (OECD), a group of wealthy nations, the U.S. ranks 32nd out of 38. Furthermore, the U.S. spends approximately $12,000 per person annually on healthcare, significantly more than any other nation.
This vast disparity between healthcare spending and life expectancy fuels ongoing commentary and political debate. A considerable portion of this spending is absorbed by the private health insurance industry. Harvard health economist David Cutler explains that “the largest component of higher U.S. medical spending is the cost of health care administration,” estimating that about one-third of healthcare dollars goes towards administration. This contrasts sharply with peer countries, even those with similar multi-insurer systems, which spend a fraction of the amount. Cutler notes the existence of entire occupations within the U.S. healthcare system, like medical record coding and claim-submission specialists, that are virtually nonexistent elsewhere.
This excess administrative spending totals around half a trillion dollars annually, according to a People’s Policy Project analysis of Congressional Budget Office data by Matt Bruenig. For every $100 spent, $16 goes to private insurance companies, and another $16 covers hospital administrative costs, leaving only $68 for actual medical services. A single-payer system, by contrast, would require just $1.60 for public insurer costs and $11.80 for hospital administration, freeing up $86.60 for care.
UnitedHealth Group, UnitedHealthcare’s parent company, profits handsomely from this inflated spending. In 2023, the company reported $22 billion in profit on $371 billion in revenue, equating to $25 per share (with dividends of $7.29 per share). This translates to a $7.29 reward for every $500 invested, despite no contribution to the actual healthcare system. Mangione’s note labels private insurers as “parasites.”
These profits are not passively generated. UnitedHealthcare has a reputation for ruthlessly pursuing shareholder value, relentlessly fighting to reduce spending on care despite record profits, as reported by ProPublica. A Senate committee concluded that the company, along with others, intentionally denied critical nursing care to stroke patients to boost profits, using rigid algorithms to cut off payments regardless of patient need. Thompson himself had been accused of insider trading before the company revealed it was facing a federal antitrust investigation.
The widespread frustration with the complexities and indignities of dealing with insurance companies—billing codes, prior authorizations, and the like—likely explains the widespread condemnation of the industry following Thompson’s death, transcending partisan lines. Doctors highlight how these profit-driven barriers delay care, potentially worsening patient outcomes and even causing deaths.
Mangione’s note expresses frustration at the lack of progress in addressing the system’s dysfunction. He cites prior critiques by Elisabeth Rosenthal and Michael Moore, stating, “It is not an issue of awareness at this point.” While the note doesn’t detail personal struggles with the insurance system, evidence suggests Mangione suffered from chronic back pain and underwent major surgery. Ultimately, driven by a combination of personal experience, systemic anger, or mental breakdown, he apparently decided to act, as indicated in an unreleased longer document: “What do you do? You wack the C.E.O. at the annual parasitic bean-counter convention.”
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