A gun with three bullets; one man dead on the pavement, one man in custody. From a distance, the death of Brian Thompson looks like any other in a uniquely violent America. But the circumstances surrounding his murder were unimaginable just two weeks ago: A reclusive gunman partially built a gun on the computer and assassinated the chairman of America’s most powerful health insurance company. As far as we can tell, the alleged shooter, Luigi Mangione, was radicalized neither by QAnon conspiracy theories nor by undercover federal agents, but by months of self-isolation following a spinal surgery that left him in chronic pain, against a health care system so fundamentally brutal that an unexpectedly large, atypically nonpartisan cohort of the population took to the internet to mock the victim.
It was an impolite reaction, with unusual savagery — not even a moment for “thoughts and prayers” — which has been examined to death over the past few weeks. In a December 17 YouGov/The Economist poll, Mangione’s net approval among respondents, while negative overall, is 15 points higher than that of Congress. He comes out positive or even among respondents 44 and younger. A former federal prosecutor said he’s “never seen an alleged murderer receive such sympathy.” Even fellow Italian-Americans rallied to Luigi’s aid: A pizza place a couple miles from Mangione’s high school put up a Luigi poster.
I can offer no new insight about how shocking the response to Thompson’s murder has been, or how thin the threshold is between the politesse of acceptable average American decorum and an ecstatic celebration of violence. I, personally, wish every family be spared the fate of the Thompsons. I also wish every family be spared the fate to which the bone-grinding machine that Brian Thompson sat atop condemns millions of others. So long as we tolerate the existence of health insurance for profit, no one will be spared.
Scam World
Fundamental to the experience of being an American is the constant suspicion that you’re being scammed. Some of those suspicions are internet-induced prodromal schizophrenia: Not every Home Depot parking lot is a human-trafficking PokéStop; tap water won’t turn your kids trans. But Americans are constant targets. We are bombarded day and night by emails, phone calls, and text messages from people who want money from us under false (or flimsy) pretenses. The infrastructure of daily life has been ceded to Silicon Valley executives, who have mangled their indispensable products in order to make as much money for their shareholders as possible, even as this rot makes those products shittier. Throw on the TV to watch a basketball game with a friend and you’ll be Clockwork Orange’d with dozens of advertisements for apps that exploit cutting-edge advancements in gambling psychology to create life-ruining addictions — with to-the-hilt support from sports leagues, lawmakers, and universities. Even the genocide in Gaza has become fodder for Twitter and Bluesky scammers running fraudulent fundraisers — possibly the most revolting con I’ve ever encountered, and one which I now barely notice as I tune it out three or four times a day.
Two days’ worth of emails Gmail flagged as spam.
Nowhere is the scam woven more tightly into our cool national fabric than in health insurance. The arrangement of our health finance system is lethal and inordinately expensive. Here, alone among peer countries, sickness makes you poor, poverty makes you sick, and any fever, fall, or freak accident, nor matter how slight, can quickly become a ritual of humiliation, degradation, bankruptcy, or death. Few are spared and none are distant. Over 20 million Americans have started a GoFundMe crowdfunding campaign to address medical costs; one in five American adults have donated to one. Only 12 percent of these campaigns reach their goals. We all know what happens to the losers: debt, if they’re lucky; death, if they’re not.
Having insurance does not spare you from these horrors. Some of the worst health care horror stories you’ll ever hear come from people with health insurance. Yet without insurance, things can be even worse; the same punishments somehow magnified. Søren Mau writes about the “mute compulsion” of capitalism: You gotta play the game or else you don’t eat. Health insurance works the same way. Get in the pit, and you might go bankrupt and your kid might die from cancer; stay out, and you will go bankrupt; your kid will die.
It is essential to the perpetuation of American society as it currently exists that we are trained to view this as the natural course of events. David Roth of Defector explained why in his reflection on the 2024 election.
“Everywhere, in every way, American culture works to prise people apart and keep them confused and worried and mean; this is much easier to do when people think of themselves only as themselves, and not as part of any greater community or project, which is why America’s reactionaries have so dedicated themselves to tearing down or splitting up those kinds of communities and projects,” Roth writes. “This is a good way to keep people working and shopping and pliable, but it is also corrosive and lonely.”
In a vacuum, it is unsurprising for any American to go mad when confronted with this atrocity; in the real world, we are made hopeless by the state-sponsored agreement that this quiet violence is the ordinary cost of doing business. Mangione’s manifesto — or, at least, the one attributed to him — describes a need to resolve the contradiction between what everyone knows and what everyone has to believe with lead and “brutal honesty.”
This is not a desirable arrangement, and the last serious attempt to reform American health finance, the Affordable Care Act, along with its subsequent decade of slapdash policy tweaks, failed to prevent the conditions that made this assassination possible. These tiny reforms, as titanic and final as they’re sold to us as, will continue to fail. The terrible mountain of bodies and its shadow of mass suffering are normal, expected outcomes for the American model of health finance.
There is no recourse in the existing health care system, and we are offered no vehicle for change in mainstream politics. What happened on December 4 was unique in that it was an inversion of the violence which undergirds our heath finance model. The only possible rearrangement of health finance in America that can prevent this continual onslaught of death is a single-payer health care system like Medicare for All. Absent a political movement, this murder will become nothing but a memento mori — a meme around which distressingly online Zoomer dance clubs will throw occasional theme nights throughout the duration of Mangione’s trial, until we all forget about it and pay next year’s ever-higher premiums, angrier and poorer but submitting still to the extortion into which we have been born.
American Excellence
Shit is fucked up and bullshit. Part of the reason everyone and their maxed-out 401k is writing essays about The Scandalous Reaction to the Assassination is that frustration with American health finance has metastasized to an extent that modern political and media institutions are unable to taxonomize. Hating health insurance is no longer identifiable as a specifically left-wing position, which is scary to people who make their trade confidently telling you how the world works. We now live in the era of “Bailamos” — nothing is forbidden anymore.
Based on the reaction to the assassination, the vibrant Medicare for All movement pre-2020, and every interaction I’ve ever had talking to people about their health care, I know you know you’re being fucked over. Let me explain how.
The fundamental tension of American health finance is this: It’s very expensive to take care of sick people, and it’s not profitable to pay for their health care. The American approach toward this problem has been a patchwork series of accidents, union struggles, government subsidies, and tax incentives that over 70 years developed in more-or-less unguided fits and bursts. This isn’t controversial or secret; all the C-levels making bank off the arrangement sit around looking at the State of Things, write “Wow, look at all these complicated problems!” in The New York Times or wherever, then go home to sit surrounded by the tremendous piles of money they’ve accumulated by their maintenance of the problems they lament.
Nobody (or, at least, nobody normal) can afford to pay for their own health care completely out-of-pocket. Thus the invention of insurance: Everyone puts a little bit into the pot (this would be your insurance premium), and when it’s your turn to receive health care — when you have a kid, or get bitten by a raccoon, or come down with lupus — you take a share of the accumulated pile of money to pay for it (or, in the United States, some of it). Not many people need health care at the same time, and for the people who do need it, can be very expensive. In a given year, 50 percent of medical expenses come from 5 percent of the population. The borders of this 5 percent are porous; in much the same way that poverty works, some years you’re in need, and most years you aren’t.
In America, we largely delegate the function of insurance to private, for-profit companies (don’t let Blue Cross Blue Shield’s “not-for-profit” status fool you). Thing is, private companies really don’t want to pay for sick people’s health care — it’s expensive, and spending a lot of money is a hard way to make a profit. Meanwhile, the price of care increases every year, totally unassociated with how much health care people receive. So insurers raise the price of premiums, and finagle little ways to saddle you with more and more of the cost: deductibles, copays, and claim denials.
In the 1960s, the government stepped in. Poor people (who couldn’t afford premiums) and elderly people (who are generally much more expensive than younger people to insure, and therefore couldn’t afford their premiums either) were dying uninsured. Horror story after horror story and protest after protest wielded by well-organized advocacy groups shocked the machinery of the state into action, leading to the creation of Medicare and Medicaid, which generally insure elderly and poor or disabled people respectively. Insurers were effectively spared the costs of insuring people who need health care — an arrangement they found could only be improved with the introduction of privatized Medicare and Medicaid plans about 30 years later. Now, thanks to generous and easily gameable government subsidies, otherwise unprofitable patients can live up to their potential and be cash cows for private insurers, though privatized Medicare is becoming a slightly less tantalizing option as senior citizens begin actually using their insurance plans again following a lull during the height of the COVID pandemic.
You might see some pundit or another wriggle his pudgy little nose and point out that everyone getting mad about insurance is being irrational — after all, UnitedHealthcare “only” turns a 6 percent profit! They neglect to mention that 6 percent comes from $280 billion — $16 billion we pay to one company alone that doesn’t go toward anyone’s health care. That’s not even counting the roughly 17 percent private insurers spend on administrative costs, about six times what Medicare spends on administration. Depending on how you measure it, between $500 billion and over $1 trillion of our total national health care expenditures went to administrative costs, largely generated by the card-shuffling between providers and insurers.
The CEOs of insurance companies will whine about how costs are increasing. They’re correct! But the insurance industry altogether isn’t really that upset. The amount of money they’re required to spend on health care (their “Medical Loss Ratio,” or MLR) is a fixed percentage of their total premium revenue, often 15 percent, and if costs keep going up, so too do premiums — good news for your insurer, who now gets to keep 15 percent of $60 billion (or whatever) instead of 15 percent of $50 billion.
This is not meant to depict health care providers as blameless. There’s a lot of waste in health care. Prices are totally unmoored from costs. Two MRIs from the exact same MRI machine can have a 4.5x cost difference based on who’s paying for them. Pharmaceutical companies perform incredible sleight of hand to artificially extend monopolies on expensive drugs, and Congress for years has banned Medicare from negotiating lower drug prices. Sometimes there’s outright fraud, usually perpetrated on the most vulnerable patients — 90 percent of hysterectomies are unnecessary. Doctors, human as any of us (despite what they might like you to believe), often prescribe on faulty memory, professional superstition, and vibes, not current scientific evidence. Hospitals go to great lengths to make pricing completely opaque — list prices are artificially inflated as a method of negotiating better prices from insurers, so uninsured patients are stuck with insane costs. Giant nonprofit megahospitals routinely hide information about financial assistance from eligible patients while paying their workers so little they have to open food banks for their own employees. The rot runs deep.
America’s private insurance network is supposed to be a counterweight to all this graft. It’s failed; after 70 years, we must consider that perhaps it doesn’t want to succeed. Insurers focus on reducing the amount of health care people seek instead of taking on the prices at the core of the problem of health care spending. (“It’s the prices, stupid,” quipped legendary health economist Uwe Reinhardt.) Provider-payer squabbling is largely kayfabe: No matter what happens, the people making money keep making money, the overwhelming majority of it from the government, while individual workers or patients are left to suffer.
It’s hard to quantify how many people die because of our health care system alone, because it’s hard to distinguish un- or underinsurance from things like gun violence or overdoses within the gap between America’s excess mortality rate and those of peer countries. What we can quantify about the impacts of our health finance system on poverty is staggering: 44 percent of working-age Americans are either uninsured or underinsured, meaning they have insurance too expensive for them to use. KFF finds that 41 percent of American adults carry debt from medical or dental bills, while the Commonwealth Fund finds that 14 percent of adults under 65 have medical debt of over $2,000. One in five adults with medical debt think they’ll never be able to pay it off.
Commonwealth found that nearly 60 percent of underinsured adults avoided seeking health care because they were afraid of the cost. Two-thirds of adults who avoided care because of cost said their problems had worsened because of it. Poverty has a stronger association with mortality than nearly any other cause around — the only things that cause more deaths than poverty are smoking, cancer, and heart disease.
There’s no room for equivocation: Health care costs kill people.
Social Murder, Inc.
UnitedHealth Group, the parent company of Brian Thompson’s UnitedHealthcare and the fourth-largest corporation in America by revenue, was essentially designed in the great laboratory of the market to demonstrate how this all happens. STAT News has been on the beat for a long time, and this year Maureen Tkacik put the company in her crosshairs at the American Prospect.
Here are some of the tactics UHG and other health insurers use to game the system:
- Upcoding: A significant portion of UHG’s revenue comes from Medicare Advantage, or its privatized Medicare plans. The government pays Medicare Advantage insurers a fixed subsidy per person to insure seniors, based on bids the insurers place in advance. Thing is, some seniors are naturally a lot more expensive than others. Given the option, UnitedHealth Group would insure only the seniors who don’t need their insurance so they could keep the entire subsidy for themselves. To bribe them into playing nice, the Centers for Medicare and Medicaid Services (CMS) pay an additional subsidy to insurers if their members have certain diagnoses that indicate they may be costlier patients: If CMS pays $1,000 per default senior per month, a senior with a diabetes diagnosis might come in at $1,200 or $1,500.
Naturally, this means insurers are interested in getting as many seniors as many diagnoses as possible, regardless of whether they’re actually receiving treatment for them. In aggregate, this upcoding is forecast to cost the government up to $80 billion a year in fraudulent payments. UnitedHealthcare, which covers about a third of all Medicare Advantage enrollees nationwide, is one of the worst offenders, deploying an army of 90,000 physicians to squeeze as many possible diagnoses out of as many patients as possible.
- Consolidation: One of the more distressing trends in health finance is an insane amount of vertical consolidation in the years following the Affordable Care Act. The distinction between “payer” and “provider,” once an easy heuristic for understanding where money goes and how, is being eroded as insurers buy health care companies and medical providers buy insurers. UnitedHealth Group, naturally, is leading the charge. This is ominous. One reason is “self-dealing.” Insurers can get around their regulated 80-85 percent MLR — how much of their revenue they’re required to spend on health care — by buying up hospitals and clinics and paying their own providers inflated prices. This means it looks like the insurer is spending a lot on health care, but ultimately they’re just passing the ball between one hand and the other. UHG is one of the worst offenders. Up to 40% of its revenue is from internal transactions. Colonoscopies, for example, are a traditional point of tension in insurance. Insurers are required to pay for them in full (if they’re preventive), which leads to a lot of disputes about whether screenings are preventive or diagnostic (diagnostic procedures punt the cost back to the patient). UHG found a great workaround: Just buy the gastroenterologists and pay them — pay themselves — three times what competitors pay other physicians.
- Systematic claim denials: Much ado has been made about UnitedHealth using a machine learning algorithm to kick seniors out of rehab. In 2020, UHG dropped $2.5 billion to acquire NaviHealth, whose nH Predict rehab care management software came under fire for kicking amputees and stroke victims out of nursing homes weeks or even months before their physicians said they were ready, well below Medicare’s own already-limited threshold for care. Sometimes NaviHealth’s assessments were made before a patient’s own physicians had examined them. A class action lawsuit against UnitedHealth alleges that the tool had a “90 percent error rate.” UnitedHealth contracts nH Predict to other major Medicare Advantage insurers.
Nearly two centuries ago, Friedrich Engels coined the term “social murder” to describe how the living conditions that led to the premature deaths of British workers were, though occluded, not natural accidents but the product of aggregated political decisions in service of the normal function of the economy. The framework fits in America, too; as much as one man shooting another is an act of killing, so too is the arrangement of companies, institutions, and incentives that result in poor men dying up to 15 years sooner than rich men, white people living five years longer than Black people, and an 8-year difference in life expectancies between poor and rich ZIP codes five or six miles apart.
Many have pointed to Mangione’s spirited Goodreads review of Industrial Society and Its Future — better known as Ted Kaczynski’s “Unabomber Manifesto” — as foreshadowing the assassination. Kaczynski argued that the technological developments of mass society inevitably dominate and restrict human autonomy and that the only paths available to preserve human freedom were revolution or withdrawal. In light of the “nursing home AI” scandal, it is tempting to draw a parallel between the American health finance system and the powers of the Industrial Revolution Kaczynski lamented: Both are domineering forces that relentlessly reorder humans around the whims of technology.
But that lets the people who put us here off the hook. Nobody’s put it better than epidemiologist and writer Abby Cartus.
“I think it matters whether we want to understand the health insurance industry and its evils as an autonomous technical behemoth, superficially at the level of algorithmic decisions, or whether we want to understand it as a way of organizing technological and economic resources, incentives, and choices given the political-economic structure of capitalism,” Cartus writes. She continues: “The former — the story of autonomous technology — strips away the industry’s guilt and […] misdirects attention that should be focused like a white-hot laser beam on the real problem: private, for-profit health care, and the thugs who administer it.”
Viewing the social murder of American health finance as some sort of uncontrolled, ambient force that, like a ghost or a dog, just does things arbitrarily, is to excuse the aggregate human decisions which create and maintain this condition. The wretched circumstance of health finance in America may not be intentional, but neither is it accidental. It emerges directly from its organization according to the sole principle of having to create shareholder value.
December 4 isn’t how things are supposed to work. Executives are supposed to look down from atop the great murder machine, not get crushed under its weight. Judging by the rush of calls to personal security firms from the moneymaker class and the small army of cops New York City Mayor Eric Adams led to march Mangione to his arraignment, this sudden inversion scares the hell out of them. But violence — the loud kind — will inevitably erupt from an institution created and nourished by acts of violence.
Brian Thompson may not have pulled any triggers himself — his friends describe “BT” as a decent man concerned with the state of American health care, God bless him; aren’t they all. As the executive of the most powerful private insurer in America, the core of the most powerful private medical entity in the world, he commanded an institution inseparable from the American machine of social murder. If all lives are equal, then all deaths are too.
Clawing Up
What do the Mangione fundraisers, the club nights, Ben Shapiro’s YouTube comment section, the stickers, the TikTok folk hero ballads mean? They mean that a lot of people hate their insurance — a lot — in a way that transcends conventional ideology or political expression.
Part of the reason the reaction to the shooting came as such a shock is that many people who tip poorly or write newspaper columns assumed the frustration about American health insurance was limited to the cranks and unwashed longhairs of the Medicare for All movement, which had been cauterized quickly and painfully after Joe Biden seized the Democratic nomination in 2020. Policy decisions since have reflected this self-assurance, throwing yet more public money into the pit of for-profit companies: Among the most substantial health finance policy achievements of Biden’s presidency was increasing subsidies to insurance companies selling individual marketplace plans. These subsidies have become load-bearing insurance infrastructure, and without their projected $335 billion over the next decade, millions of people will be even less able to afford their health care.
Gains made under the Affordable Care Act have been erased. More people are insured than they were before the ACA, but many more people are underinsured. Some premiums for employer-sponsored insurance plans have increased by 50 percent since 2011; out-of-pocket spending (in addition to premiums) is up 16 percent from where it was pre-ACA. The Affordable Care Act was a series of elaborate bribes designed to persuade the for-profit entities that run American health care to be a little less ferocious; a decade later, Cerberus has broken free of his leash. Every policy tweak in the mold of the past 10 years of American health policy will fare similarly: They are little more than incredibly expensive bandages slapped onto an ever-spreading wound.
The refusal of the 2020-2024 Democrats to reject the limitless money of the profiteers and seize on the deep bipartisan fury against the health insurance system was a predictable (some might say inevitable), disastrous, and world-changing own-goal. While most of the party is focused on making sure nothing ever changes, some politicians trying to catch the spirit have come out to wring their hands and talk about how we need reform. They and many others will suggest policies over the next few months — some lightweight, like restricting AI oversight of claim denials; some essential but incomplete, like antitrust legislation against UnitedHealth and its peers. Elected officials are incapable of doing anything more unless they are willing to jettison the idea that health care should be arranged according to the whims of shareholder value — an idea lodged, like Excalibur, into the foundation of our political economy. They, or their low-VORP successors, will be unwilling to do so unless there is concerted political effort to demand it. This is not a question of policy, but power.
Individual acts of violence will not bring about the systemic reforms required to obviate the institutionalized extortion of private insurance. I don’t imagine a mass militia of patients will (or should) rise up and revolt against their medical oppressors with an armory of 3D-printed guns. If anything, the extremely “median voter” ideology of Mangione instead suggests the potential for a massive political coalition that can be directed toward serious health care reform.
We can find inspiration from how ADAPT and other disability rights organizations organized in mass groups and threw their bodies on the line to preserve Medicaid financing and the Affordable Care Act under Donald Trump. We can look to Reclaim Idaho, the nonpartisan mass movement that expanded Medicaid in the state through a ballot referendum in 2018. We should not find solace in campaign promises toward tweaky minor reforms that, through their victories, kill momentum for more serious change.
Whether you believe health care is a human or civil right or if you just want to maximize efficiency while guaranteeing universal coverage, the only policy path forward is an expanded and improved Medicare for All, a system in which premiums and deductibles are replaced with fairly distributed taxes and all health care spending is paid by the federal government, which uses its tremendous purchasing power to drive costs down and guarantees patients need spend nothing out-of-pocket. Twenty-two separate studies, including one by the conservative Mercatus Center, find that some version of Medicare for All or another would save money compared to our current privatized arrangement. Other countries’ health care models instruct us that any introduction of fragmented, privatized insurance creates gaps into which the sickest or poorest people fall. I have argued elsewhere that a Medicare for All model is absolutely necessary (but not sufficient in and of itself) to address the larger problems which sicken and kill the people we love.
It’s been five fallow years for health justice. Is this the spark we need, or is it just a directionless moment of cultural catharsis? Will Brian Thompson’s death bring us to the doors of our neighbors, the halls of our legislatures, and the streets of our cities? Will someone — a union leader, a politician, a community organization — be able to capitalize on this kinetic energy the way Bernie Sanders did, this time more prepared to face the extreme resistance of capital, or is the conquest of the boardroom over the living room absolute? I’m not optimistic, but I’m hopeful; I’m putting my boots on. I gotta. There is no alternative but the nihilism of lonely Luigi Mangione.
