Luigi Mangione has a lot to say about American healthcare. Does he have a point?

By now, everyone knows Luigi Mangione---the man with a bad back, a 3D-printed gun, and a handwritten manifesto---who is being charged with the murder of UnitedHealthcare CEO Brian Thompson. The public reaction has been notably polarized: scrolling through social media, you'll find countless posts portraying him as a folk hero taking on the behemoth of the American healthcare system, with hashtags like #FreeLuigi trending for weeks. On the other side, there are plenty of voices condemning the glorification of violence and cultural obsession with vigilantism.

I'm not here to throw a log on that fire. Plenty of others are doing an excellent job of debating whether Luigi's actions were justified or not, and frankly, I don't have much to add to that conversation. What I can offer is a perspective on the true sources of dysfunction in American healthcare. As a PhD candidate in Health Policy at Stanford, I've spent years thinking the intricacies of our healthcare system, so I can offer a perspective on the (real and imagined) root cause of these problems.

Truthfully, we don’t know a lot about Luigi’s ideology or motivations. Thanks to journalist Ken Kippenstein, we have a copy of the manifesto he had on his person at the time of his arrest. Though it doesn’t include a lot of detail, this gives us some insight into his perspective on healthcare:

Frankly, these parasites simply had it coming. A reminder: the US has the #1 most expensive healthcare 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 as our life expectancy? No the reality is, these [indecipherable] have simply gotten too powerful, and they continue to abuse our country for immense profit because the American public has allwed [sic] them to get away with it. Obviously the problem is more complex, but I do not have space, and frankly I do not pretend to be the most qualified person to lay out the full argument. But many have illuminated the corruption and greed (e.g.: Rosenthal, Moore), decades ago and the problems simply remain. It is not an issue of awareness at this point, but clearly power games at play. Evidently I am the first to face it with such brutal honesty.

So…does he have a point?

Claim 1: The US has the #1 most expensive healthcare system in the world, yet we rank roughly #42 in life expectancy.

This is basically true. According to data from the World Health Organization (WHO) Global Health Expenditure data, the U.S. spent around $12,000 on healthcare per person in 2021, the highest in all measured countries. Switzerland, the next highest spender, spent just over $10,900 per person. The WHO also ranked the U.S. 45th in life expectancy in 2021---a little off from Luigi’s numbers, but that much is forgivable for a handwritten note taken from him by police at a McDonald’s in Pennsylvania.

How do we interpret these statistics? It’s easy to assume, based on these numbers alone, that American healthcare is uniquely wasteful or ineffective when compared to that of other countries. This may be true (I’ll address it below). But I think it’s important to keep in mind that healthcare does not drive life expectancy as much as other social determinants of health. In fact, our best estimates suggest that health care, including access to and quality of healthcare services, accounts for less than 17% of variance in premature deaths. The other 83% is shaped by things like what we’re eating, how much support we get from our friends and family, whether our jobs are safe, the air we breathe, and the stress we experience in daily life. Social and economic determinants (like income, social support, education, and neighborhood safety) explain between 15% and 46% of premature mortality, whereas behavioral and lifestyle factors (diet, exercise, smoking, etc.) explain 16% to 65%. This is particularly relevant to life expectancy in the U.S., which has higher levels of income inequality, child poverty, gun deaths, and drug use than most peer nations. All this is to say that factors like socioeconomic status, education, environment, and behaviors have a much larger impact on disease and death than healthcare access and quality. But 17% is still a lot, and if we’re spending more than any other country on healthcare, we should be asking whether we’re getting our money’s worth.

But first: why are we spending so much on healthcare? The short answer: it’s a system riddled with inefficiencies, bloated costs, and inadequate price controls. I’ll address each of these factors below.

For starters, our healthcare system has very high administrative costs. These expenses are not directly related to patient care but are necessary due to the complexity of the healthcare system. American healthcare is fragmented, with a mix of private insurers, employer-sponsored plans, Medicaid, and Medicare. This complexity leads to higher costs related to billing, claims processing, and compliance with various regulations. Studies estimate that 15-25% of U.S. healthcare spending goes toward administrative expenses---significantly higher than in countries with single-payer systems, which tend to be much more streamlined.

But that’s not all. Every high-income nation, except the United States, guarantees health coverage for all residents. In the U.S., not everyone has health insurance: on average, around 9% of the U.S. population is uninsured and another 23% of Americans are underinsured, meaning that they have health insurance but still struggle to afford care due to high deductibles and coinsurance. Not only is this bad for the health of those people, it actually increases the costs of healthcare for everyone. Uninsured and underinsured individuals often delay seeking medical care they cannot afford, which means treatable conditions can become more severe, requiring more complex and expensive interventions (e.g., major surgeries instead of early preventive care). Likewise, many of these patients rely on ERs for medical care because they do not have access to primary care physicians. ER visits are significantly more expensive than regular doctor visits, leading to increased overall healthcare costs. When uninsured individuals cannot pay for their medical treatments, these debts are passed on to the taxpayer, since government programs cover the bulk of uncompensated care provided by hospitals.

So we’re spending a lot on healthcare---but are we getting our money’s worth? For starters, let’s consider what it even means to “getting our money’s worth” when it comes to healthcare. For researchers like me, this comes down to cost effectiveness: when we spend money on healthcare, it should be increasing the length and/or quality of a patient’s life. Our goal as researchers is to measure this: for each dollar we spend on healthcare, how much improvement do we get in terms of longevity and quality of life? A cost-effective procedure is one where we get a big increase in length or quality of life for a good price.

I don’t mean to say that cheaper is better. For example, a treatment can be both cheap and ineffective---for example, drinking chamomile tea to treat cancer. It costs almost nothing, but it also doesn’t work. A treatment can also be very effective and very expensive: consider medications like sofosbuvir which revolutionized Hepatitis-C treatment but were extremely expensive when first developed.

This conversation can sometimes feel indelicate, or even offensive. After all, aren’t we placing monetary value on a person’s life? Shouldn’t we spend whatever it takes to make ourselves healthier?

I would argue no. Consider this example: I have a pill that cures the common cold. The next time you have a runny nose or cough, the annoying kind that would last around 48 hours, you could take the pill and be immediately symptom free. One pill costs $5. Would you take it? I certainty would!

What if the pill cost $500? Or $1500?

Just because a treatment works doesn’t mean it’s worth the money. I believe that an effective health system is one which spends money thoughtfully, ensuring that the prices of treatments are justified by their positive effects.

Now, this is the place where I believe health insurers get a bad rap, because they are the only players in our health system who actually want to lower costs. Everyone else---doctors, hospitals, medical device and pharmaceutical companies---make more money when healthcare spending increases. This is bad for patients, because we’re the ones paying for this whole thing. Medicare and Medicaid are funded by payroll taxes, and employer-sponsored health insurance is paid with wage deductions, which means that all healthcare spending ultimately comes out of our paychecks. In fact, the increasing cost of healthcare is the reason American wages have been stagnant since the 1970’s.

I don’t mean to suggest that those other players (doctors, hospitals, medical device and pharmaceutical companies) are the “bad guys” here. All of these organizations are chock-full of hard-working professionals committed to improving the health and well-being of their communities.

At the same time, financial incentives do affect human behavior, even if the humans are doctors. It’s one of the most well-documented phenomena in healthcare research: when a treatment is more profitable, doctors provide more of it. They swear that they don’t---and they genuinely believe that they don’t---but they simply do.

This is why health insurers play such a critical role in a nation’s health system. They have a disproportionate amount of power in determining what treatments are available and how much they cost. Insurers are meant to function as a check on excessive spending, pushing back against unnecessary or overpriced treatments to keep healthcare costs in check.

Obviously, something is going wrong in America given that we have seen over 50 years of runaway growth in healthcare spending. Why aren’t insurers doing their job? This leads us to Luigi’s next point.

Claim 2: Insurance companies have simply gotten too powerful, and they continue to abuse our country for immense profit.

This is probably true. The issue of profit motives in healthcare is a complicated one, and many experts have legitimate differences of professional opinion as to whether profit motives are fundamentally helpful, harmful, or neutral within the health sector. This is an extremely complex discussion that’s beyond the scope of the current article. (If you want to learn more, you can find a thoughtful, balanced exploration of different approaches to healthcare in T.R. Reid’s The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care).

That said, in our current healthcare system, competition between health insurance companies should keep prices low---but this often isn’t the case. A 2022 report by the Government Accountability Office found that in at least 35 states, three or fewer insurers held at least 80% of the market share in both individual and employer group markets. This is a big concern because it allows health insurance companies to operate like monopolies. When a single company or a small group of dominant insurers control the market, they can jack up prices, set restrictive coverage terms, and provide low-quality service with few consequences because their patients have no other options. Without genuine competition, premiums rise, coverage options shrink, and healthcare becomes less accessible and affordable. In the extreme case, monopolies can lead to regulatory capture, where industry giants influence policies to protect their market dominance, further disadvantaging consumers.

In addition, publicly traded health insurance companies (like UnitedHealthcare) present a unique set of misaligned incentives. To explain why, I’ll provide a brief overview of how health insurance companies generate revenue and profit.

Basically the only way health insurance companies make money is through premiums---the monthly payments made by policyholders, as well as contributions from employers who provide insurance coverage to their employees. This money goes into a big pot which insurance companies then pay to your doctor, pharmacy, hospital, etc. when you need care.

Publicly traded companies face enormous pressures to report higher earnings each quarter, which means they need to constantly growing their profits. So how do health insurance companies make more money? Well, the most straightforward way would be to get more customers. By offering a better deal than their competitors, they might be able to gain more paying customers and therefore earn more profits, all while providing the lowest prices to stay competitive. Sounds amazing, right? Everybody wins!

Well, not exactly. In reality, growing their customer base isn’t always the easiest or most profitable way for insurers to raise their profits. Instead, many insurance companies focus on reducing medical expenses (the amount they pay out for patient care) rather than just attracting more customers. How might they do this? Companies may deny or delay claims, require prior authorizations for treatments, or use complex bureaucratic processes that make it harder for patients to get coverage for necessary care. Likewise, they might find ways to attract healthier, lower-cost customers while avoiding high-cost individuals (e.g., through plan designs that are less appealing to people with chronic diseases) and keep the profits.

Sounds bad, right? Because it is! Thankfully, a lot of work in Obama-era healthcare reform was dedicated to this exact issue. The Affordable Care Act now requires insurers to spend at least 80%–85% of premium revenue on actual medical care (the Medical Loss Ratio rule). By capping profit margins, this rule was designed to eliminate the incentives of health insurers to cut spending on vital healthcare expenses to raise their profits.

Though this seemed like a great policy at the time, it has unfortunately caused some unintended negative consequences. It turns out that profit motives are stronger than policymakers may have fully appreciated, and corporate health insurance companies were not simply going to accept a capped profit margin, since this would ultimately lead to stagnating profits---the death knell of a publicly traded company. Dogs still got to eat.

Remember how health insurers make money? Since profits are now capped as a percentage of total revenue, the only way for them to maintain or grow their profits without violating the rule is to raise their premiums. But the only way to raise premiums is if they spend more on your healthcare! This undermines the goal of making healthcare more affordable. It also means that health insurers---perhaps the last bastion advocating for lower healthcare spending---now has a vested interest in raising healthcare spending over time.

This is the problem with publicly traded health insurance: the never-ending need for increasing profits is fundamentally incompatible with a well-functioning health system.

Claim 3: It is not an issue of awareness at this point, but clearly power games are at play.

This is mostly true. The pharmaceutical, insurance, and hospital industries spend more on lobbying than any other sector---billions per year. In fact, 93% of Congressional incumbents running in 2024 received contributions from “Big Insurance.” These companies advocate against policies such as the ACA’s public option or Medicare expansion, which could introduce more competition and reduce their profit margins. Health insurers also fund political campaigns and employ former government officials as lobbyists, creating a revolving door that helps them maintain favorable regulations. This influence likely contributes to their ability to raise premiums, deny claims, and maintain high administrative costs, all of which contribute to the overall rise in healthcare expenses.

That said, healthcare reform is really complicated and involves a lot of difficult trade-offs. There is no “perfect” health system, because health system can be great (or terrible) in lots of different ways. Consider this trade-off: the factors that promote innovation are opposite the ones that contain costs. Encouraging medical breakthroughs like new drugs, treatments, and technologies, requires significant investment and financial incentives for researchers and companies. Investors will only agree to this if they might get a good return on investment, but allowing high prices for new treatments can make healthcare unaffordable for many. On the other hand, a system that tightly controls costs---by regulating drug prices or limiting funding for experimental treatments---may make healthcare more affordable but discourage investment in risky but potentially life-saving innovations.

Likewise, there is the trade-off between risk protection and unnecessary medical spending. Robust health insurance plans which require low copays or premiums ensure that people are financially covered when they face serious health issues, prevent medical bankruptcy and make care accessible. However, when individuals are shielded from the true cost of care, they tend to overuse medical services---even when they are unnecessary and don’t lead to improvements in their health. This can drive up overall healthcare spending, leading to higher insurance premiums or taxes to sustain the system.

Finally, there is the trade-off between expanding coverage for the uninsured and avoiding economic distortions. Ensuring that everyone has healthcare coverage improves public health, reduces preventable deaths, and can lower overall costs by preventing expensive emergency care. That said, expanding coverage often requires higher government spending, which can lead to increased taxes or cost-shifting within the healthcare system. In some cases, government intervention can also disrupt private markets, discouraging competition or innovation in insurance and care delivery.

Conclusion: He makes some valid points.

Luigi Mangione’s frustrations---however extreme---speak to a real and growing discontent with the American healthcare system. His claims, while slightly oversimplified, are largely grounded in reality: our healthcare system is the most expensive in the world, yet it fails to deliver proportionate improvements in health outcomes; our insurance model incentivizes inefficiency and profiteering; and our political system is deeply entangled with industry interests, making meaningful reform difficult.

The healthcare crisis in America won't be solved by killing more CEOs, but neither will it be solved through passive acceptance of a broken system. Real change requires sustained civic engagement: enacting legislation, supporting candidates who prioritize meaningful reform, and staying informed about policy proposals that could address systemic issues. While Luigi’s actions represent a breaking point, this also serve as a stark reminder that healthcare reform cannot wait. The cost of inaction---measured in lives lost, families bankrupted, and communities torn apart---grows steeper every year. The solutions won't be simple, but they start with an informed and engaged public demanding better from their healthcare system and their elected officials.