On December the 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 United Healthcare, America's biggest health insurer, in a pre-dawn assassination in Manhattan on December the 4th.
Mr. Mangione now faces five criminal charges in New York City, including secondary murder. He's also charged with weapons offenses and using a false ID in Pennsylvania. He's currently fighting extradition back to the Empire State, a process that could take several weeks to resolve. He left a 262 word handwritten note that included the passage, "I do apologize 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 contribute to abuse our country for immense profit. Many have illuminated the corruption and greed in the system, he wrote. Evidently, I'm the first to face it with such brutal honesty.”
Mr. Mangione belongs to a wealthy Italian-American family from Baltimore. He was the valedictorian in 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. According to friends, he suffered chronic back pain, possibly being made worse by a surfing injury. In 2023, after shopping around, he underwent back surgery. On his Reddit account, he posted an x-ray image of a spine that appears to have a three-level fusion with screws. Aside from the wisdom of operating on such a young person, with such a radical orthopedic procedure, and without knowledge of whether his insurance company paid for this, or even his post-operative care, or whether his failed back fusion even needed further interventions, all this will come out at trial, no doubt.
In fact, you can be sure his defense team will place the insurance industry on trial. The field of orthopedic and neurosurgery of the spine is being accused of supporting high rates of unnecessary elective surgeries, putting profits before patients, and not providing patient-centered, evidence-based care. Studies suggest that doing spine and orthopedic surgery for questionable indications or unsuitable candidates has become far too common. Concerningly, over 50% of lumbar spine surgeries are deemed unnecessary. US health systems are complicit in this troubling trend, having built business models reliant on facility fees paid to hospitals for procedures. Even elite hospitals ranked in US News and World Report are performing a plethora of unnecessary surgeries. Prior to his arrest, three words written on the casings of the bullets used to kill Mr. Thompson were "deny", "defend", and "depose", words used by insurance companies while rejecting claims. These popped up on social media. On TikTok, sympathizers made out the then mysterious killer was some sort of superhero, with influences signing ballads to him and getting tattoos on his face.
The killing of another human being in cold blood, from the back no less, is brutal, savage, and uncivilized. In a civil society, problems and frustrations are worked out through a nonviolent civil system. However, as others have well documented, salad bar extremism tends to occur when societies undergo socio-political restructuring. The industry and its sister conglomerates, big pharma, hospital conglomerates, and medical device companies, will finally come under the microscope as to how they, through the managed health care gatekeepers, denied care to millions.
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 refused care they thought would be covered, and 27% had insurers pay out less than expected. 40% said they 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.
Even if you can finally afford health coverage, knowing what will be covered or denied is extraordinarily difficult. 50% of Americans say they are unsure how their coverage works, that this drug or that procedure needed a prior authorization, or that their physicians do not have the time nor resources to assist with the onerous task of sitting for 45 minutes until a managed care person responds and asks for medical records and a peer-to-peer review with the physician that can take up to 30 minutes in order to get coverage for the medication, diagnostic procedure, or surgery.
Even more difficult is to proactively compare rates and get a price from a hospital prior to an elective procedure. Mr. Mangione should be tried for his crime in a court of law by a group of his peers for the murder of an innocent human being in cold blood. But we are also fed up with hearing from our patients who pay a large percentage of their income for health care. Like 30% of Medicare households spent 20% or more of their total household spending on health-related expenses, and only 7% of non-Medicare household spent 20% or more on health-related expenses. Lower income households tend to spend a higher percentage of their income on health care. Households with annual incomes under $40,000 are more three times as likely to report difficulty affording health care costs compared to households with incomes over $90,000. Something is systemically wrong with the system, with the burden of costs falling upon the lower income blue-collar worker.
In rural Indiana, when I have practiced since 2002, these changes are making it harder for my patients to even afford to see me. Those on public aid under the threat in the coming administration were able to take a Medicaid cab to see me until now. However, the blue-collar worker in the steel mills of Gary now has a high deductible and huge copay, making every therapeutic decision we make together dependent upon a generic drug alternative and a choice as to how the family spending will be allocated, anticipating a procedure.
Mangione must be tried on the act of murder, nothing less. However, the trial will open up a new and urgent debate as to the inequality of health care access in the wealthiest country of the world.
