In the early morning of December 4, 2024, Luigi Mangione, a 26-year-old Ivy League graduate, calmly walked up to an unsuspecting man named Brian Thompson and shot him in the back, executing him on a Midtown Manhattan sidewalk in a case of premeditated murder.

Brian Thompson was the CEO of UnitedHealthcare, a subsidiary of parent company UnitedHealth Group (UNH). He was in New York for UNH’s annual investor meeting at the New York Hilton Hotel.

UnitedHealth Group

UNH is an extremely profitable behemoth in an increasingly concentrated health insurance market. The company is one of the largest corporations in the world in terms of revenue and the largest healthcare company measured by that metric. As of this writing, it had a market capitalization of approximately $435 billion. During UNH’s financial presentation to Wall Street analysts, word reached CEO Andrew Witty that Mr. Thompson had been murdered, and the meeting was abruptly halted.

Delay, Deny, Depose

On December 9, following a nationwide manhunt, Mr. Mangione was captured a few hundred miles from the crime scene at a McDonald's in Altoona, PA. He has since been charged with murder and has pleaded not guilty.

It is a foregone conclusion that Luigi Mangione murdered Brian Thompson due to his seething anger toward the insurance industry, which he saw as earning excessive profits at the expense of their customers (patients) through unscrupulous tactics to evade coverage obligations.

The words "Delay," "Deny," and "Depose"—common tactics known to be used by insurers to make it difficult to obtain coverage—were found written on the bullet casings expelled from the ghost gun Mr. Mangione used to gun down Mr. Thompson in cold blood.

In many cases, anger toward health insurers is justified. (Last Friday, the Department of Justice announced that it was probing UNH’s Medicare billing practices; specifically for recording diagnoses that trigger extra payments to its Medicare Advantage plans, including physician groups the insurance giant owns.)

According to data from the federal government and The Wall Street Journal, health insurance companies process over five billion claims annually, of which approximately 850 million, or 18.5%, are denied.

Less than 1% of claim denials are appealed. Interestingly, 75% of all appeals are granted. However, “Because a lot of people won’t appeal, won’t call, don’t have the knowledge to sit on the phone—a lot of those go away,” said Dr. Ezekiel Emanuel, an oncologist and medical ethicist at the University of Pennsylvania.

In other instances, anger toward the insurance industry is unwarranted and hypocritical. Detractors of the American system point out that healthcare is delivered “free” to their citizens in other developed countries via socialized medicine. In theory, this is true; in practice, it is not.

In socialized healthcare systems such as those in Canada, the United Kingdom, and France, care is rationed. When it is provided, it often involves extremely long waits—sometimes over a year—that could make the difference between life and death. Furthermore, many treatments and medications that are standard offerings in America are not covered by socialized healthcare systems such as England’s National Health Service (NHS).

Indeed, some of the same people who quickly criticize UnitedHealthcare and other insurers for denying claims, while praising Canada’s “free” healthcare, would find it unacceptable if they had to wait months for surgery, even longer to see a specialist, or were denied access to an expensive medication due to a cost-benefit analysis. Make no mistake: that is often the stark reality in countries that employ socialized medicine.

While the American system is undeniably flawed, it is important to remember that identifying problems is easier than providing comprehensive solutions.

Folk Hero

While Mr. Mangione’s unfavorable view of the health insurance industry is far from atypical, his actions were reprehensible. Incredibly, a significant minority of people believe his actions were justified; we vehemently disagree.

Anyone celebrating Luigi Mangione as some sort of folk hero is deeply misguided at best and has a compromised moral compass at worst. Brian Thompson was a well-paid cog in the system, not its creator. Indeed, even if you disagree with everything Brian Thompson did in his professional life - from the little we knew about his private life he was also a loving father - justifying his murder is despicable and a microcosm of the lawlessness that would ensue if private citizens arbitrated disputes with violence.

Luigi Mangione is good-looking, well-educated, charismatic, and an (accused) killer. That grim fact has been lost on too many.

An Unhealthy System

Americans spend more on healthcare per capita than any other nation, yet American life expectancy is lower than that of most developed countries.

Consider this: In 2023, U.S. healthcare spending totaled close to $5 trillion, averaging approximately $13,400 per person, up 7% from $12,500 in 2022. As of 2022, the average life expectancy for an American was 78.4 years. Those numbers are astonishing—and depressing when compared with our peers.

• Germany: $7,300 per person; life expectancy: 81 years
• Canada: $5,900 per person; life expectancy: 82 years
• France: $5,500 per person; life expectancy: 82 years
• United Kingdom: $5,300 per person; life expectancy: 81.6 years
• Australia: $5,300 per person; life expectancy: 83 years
• Japan: $4,200 per person; life expectancy: 84 years

The Japanese diet is rich in fish and vegetables, whereas the American diet is high in processed foods and sugar. Japan has the lowest rates of gun violence per capita in the world, while America has the highest. Some reasons Americans spend so much on healthcare yet live shorter lives are not directly associated with a grossly inefficient and distorted healthcare market. Others are. Here are a few:

Price Transparency

Americans routinely overpay for healthcare services because of a lack of price transparency. Unlike nearly every other market, healthcare consumers (patients) cannot compare costs or shop for the best value.

Try this simple test: the next time you visit a doctor for a procedure, ask the front desk how much it will cost out of pocket or how much your insurer will be billed. More often than not, they won’t know. Imagine buying a bar of soap on Amazon without seeing the price or walking into a car dealership where no vehicle has a sticker price. It’s absurd—but that’s how our healthcare system operates.

Of course, healthcare is more complex than other consumer goods, but that does not justify a total absence of price transparency, particularly for standard procedures. This opacity breeds waste, inefficiency, and even fraud.

Consider two doctors at different hospitals. Dr. Cure, a highly respected physician, performs a standard procedure at his reputable hospital for $5,000. His patient outcomes are in the top decile compared to his peers. Meanwhile, at a lower-rated hospital 20 minutes away, Dr. Doom charges $7,500 for the same procedure, yet his patient outcomes are in the bottom decile. In a rational market, patients would flock to Dr. Cure. However, without price transparency or accessible outcome data, most patients remain unaware of this stark difference. The economic incentive to seek out the best care for the lowest cost simply does not exist

Malpractice

Many honest medical malpractice attorneys fight for justice for patients who have been legitimately wronged. However, the system is also rife with exploitation. Some attorneys file frivolous lawsuits hoping for quick settlements, while others pursue litigation hoping to secure a large payout. The result is an atmosphere of fear, where doctors practice defensive medicine—ordering unnecessary and costly tests or procedures to shield themselves from potential lawsuits.

While actual malpractice should continue to be addressed, excessive litigation distorts medical decision-making and drives up healthcare costs for everyone.

Penny Wise & Dollar Dumb

Health insurance companies often operate with short-term cost-cutting measures that ultimately lead to higher long-term expenses. The way physicians are compensated further exacerbates inefficiencies.

Doctors are typically paid per procedure, test, or operation, many of which are necessary—but not for time spent with patients. As a result, the system incentivizes a high volume of procedures rather than preventive care. A 30-minute conversation about diet, exercise, and lifestyle changes could dramatically improve a patient’s long-term health, reducing the need for expensive interventions down the road. However, since doctors are compensated so little for such discussions, they have little economic motivation to engage in them. This is perverse. A smarter approach would reward doctors for delivering effective, long-term health solutions rather than simply performing more billable procedures.

The Cost of Life

One of the most emotionally difficult but economically significant issues in healthcare is the disproportionate amount of spending on patients in their final weeks of life. Studies indicate that between 10-12% of total U.S. healthcare spending occurs in the last three months of a person’s life, and between 5-6% is spent in the final month alone.

That means out of the nearly $5 trillion the U.S. spends annually on healthcare, $500-600 billion is allocated to patients who may be comatose, on ventilators, or in a persistent vegetative state with little to no quality of life. This spending is a major driver of escalating healthcare costs.

Most Americans cringe at the idea of spending caps and point out that in Europe health care is free. They choose to ignore the fact that European countries have implicit or explicit spending limits on end-of-life care.

We are not medical ethicists; it is not appropriate for us to arbitrate what is fair. That said, it is worth considering encouraging realistic conversations about end-of-life wishes and aligning economic incentives to prioritize quality of life over aggressive, often futile interventions.