Luigi Mangione’s manifesto reveals his hatred of insurance companies

Homicide investigations are like bankruptcies: they come along gradually and then all at once. On December 9th, Luigi Mangione, a 26-year-old engineering graduate of the University of Pennsylvania, an Ivy League school, was arrested and charged with murdering Brian Thompson, the ceo of UnitedHealthcare, America’s biggest health insurer, in a predawn assassination in Manhattan on December 4th. The arrest came after five days of frenetic investigation in which police seemed to have almost no leads at all. The fugitive was finally captured in a branch of McDonalds in Altoona, a town in central Pennsylvania, after a member of staff recognised his face from a security camera photo circulated by the police.

Mr Mangione, of course, is legally innocent until proven guilty. But the public evidence against him is piling up. Police say the arresting officers discovered a fake New Jersey id of the sort the killer apparently used to check into a hostel in Manhattan, as well as a 3D-printed gun, a silencer, and a bundle of cash. (Mr Mangione apparently disputes this last detail). There was also a 262-word handwritten note that included the passage: “I do apologise for any strife or traumas but it had to be done. Frankly, these parasites simply had it coming.” Health insurers, he wrote, are “too powerful, and they continue to abuse our country for immense profit.”

Despite his writings, Mr Mangione did not seem determined to get caught. He skillfully eluded his pursuers. He apparently arrived in New York and left again by bus; covered his face for much of his time in the city, may have used a “burner” phone; and paid for things exclusively in cash. Searches in Central Park had turned up a backpack that the killer had apparently discarded, but it contained only a jacket and a bundle of Monopoly money. Had he not revealed his face to a security camera for a few seconds in the hostel, or been recognised by an eagle-eyed burger flipper, he might very well still be free.

Mr Mangione now faces five criminal charges in New York City, including second-degree murder. He is also charged with weapons offences and using a false id in Pennsylvania. He is currently fighting extradition back to the Empire State, a process that could take several weeks to resolve. He will then have to plead formally to the charges. His lawyer suggested he intends to plead not guilty.

What could have inspired the killing? Mr Mangione’s short note suggested a calculating desire to wreak revenge on America’s health-care system. America, he correctly noted, has the most expensive health care in the world, but life expectancy has stagnated. “Many have illuminated the corruption and greed” in the system, he wrote. “Evidently I am the first to face it with such brutal honesty.”

Biographical details add some context. Mr Mangione belongs to a wealthy Italian-American family from Baltimore. He was the valedictorian of his elite private school in the city. After studying computer science and graduating from Penn in 2020, he lived in Hawaii, working as a data engineer for TrueCar, a car-buying website. Though clearly fit and active, according to friends in Hawaii, he suffered chronic back pain, possibly made worse by a surfing injury. In 2023 he apparently underwent back surgery. On his Reddit account, he posted an X-ray image of a spine with several bolts implanted into it. About six months ago he disappeared, cutting contact with friends and family, until reappearing in Altoona.

If his goal was to get America discussing its health-care system, Mr Mangione seems sure to succeed. In the days leading up to his arrest, three words written on the casings of the bullets used to kill Mr Thompson—“deny”, “defend” and “depose”—seemingly intended to echo words used by insurance companies while rejecting claims, became a meme. On TikTok sympathisers made out the then mysterious killer was some sort of superhero, with influencers singing ballads to him and getting tattoos of his face.

Certainly frustration with insurers is growing. According to a survey conducted last year by the Kaiser Family Foundation, a health policy think-tank, in the preceding year 18% of Americans were refused care they thought would be covered, and 27% had insurers pay out less than expected. Two-fifths say that they have had to go without health care because of insurance limitations. In recent years denial rates have been rising, while insurers have adopted new tactics (such as the use of artificial intelligence to make determinations) that are deeply unpopular and have produced some shocking errors. Knowing what will be covered or denied is extraordinarily difficult, even for professionals. Around half of Americans say that they are unsure how their coverage works (see chart 1). The other half are overconfident.

The tricky thing is that insurers are hardly the only villains in this story. UnitedHealthcare’s net profit margin is about 6%; most insurers make less. Apple, a tech giant, by contrast, makes 25%. Insurers are forced to deny coverage in large part because the firms’ resources are limited to what patients pay in premiums, sometimes with the help of federal subsidies. Yet every other part of America’s health-care system incentivises providers to overdiagnose, overprescribe and overcharge for treatment, a lot of which is probably unnecessary. Many in-demand doctors refuse to accept insurers’ rates, leading to unexpected “out-of-network” charges. Hospitals treat pricing lists like state secrets. America’s enormous health administration costs (see chart 2) are bloated by the fact that almost any treatment can lead to a combative negotiation between insurer and provider.

America has fewer doctors per capita than almost all other rich countries, and over one in four doctors earns more than $425,000. Yet a tight federal cap on residencies stops more being trained. And much treatment offered to Americans (and either paid for or refused by insurers) simply would not be offered at all in more statist countries. Mr Mangione’s back surgery is in fact a revealing case in point. The details are unclear, including whether insurance paid for his treatment. But his Reddit account suggests that he shopped around doctors before persuading one to conduct a “spinal fusion” surgery. Elsewhere, the number of such surgeries has declined over the past decade because research shows them to be ineffective compared to simpler treatments. Yet in America the number has continued to rise.

Sadly, changing health-care policy is easier to talk about than to do. And one irony of Mr Mangione’s writing is that, while it is true that American health care is expensive and often ineffective, that is not clearly linked to America’s lagging life expectancy. Indeed, one notable contributor to shorter lifespans has nothing to do with doctors. That is, the 20,000 or so murders committed each year with guns. 

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