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When I met Luigi Mangione He misunderstood human agency


December 24, 2024   8 mins

After the suspected killer of UnitedHealthcare CEO Brian Thompson was revealed to be Luigi Mangione, a bright young man from a well-to-do family, thousands of pundits rushed to tell us why he did it. I, however, held back because, unlike them, I had actually met Luigi.

I found it hard to say anything coherent initially, amid a torrent of requests for comment, because my mind was a storm, constantly replaying memories of my interactions with the suspect, trying to find meaning in even our most banal exchanges.

In the intervening days, I have developed some detachment from the situation, and now feel clear-headed enough to offer my full opinion.

Luigi first reached out to me via email on 6 April. He said he was a long-time fan of my work, and had just purchased a $200 founding membership to my blog, which entitled him to a two-hour video-call with me. A month later, on 5 May, we had our chat.

He was warm and gregarious from the outset, praising my writing and telling me how excited he was to speak with me. He said he was on holiday in Japan, and that he loved many aspects of the culture there, such as the sense of honour, but believed the country was full of “NPCs”, that is, people who don’t think for themselves. He then told me a story he’d first mentioned in an email. One morning he saw a man having a seizure in the street, so he ran to the nearest police station for help. On their way back to the man, who was seizing on the ground, the police refused to cross any street if the stoplight was red, even if the road was empty. For Luigi, this story represented “a lack of free will” in Japan, by which he meant a lack of agency.

I quickly realised that agency was a major concern of Luigi’s, especially as he mentioned three articles of mine which had particularly resonated with him, all of which describe threats to human autonomy.

He went on to explain why he felt Japan was the future dystopia I’d warned about in some of my writings. He spoke of the hikikomori, Japanese men who spend their lives alone in their bedrooms, sedating themselves with video games, porn, and other shallow entertainments. For Luigi, such people had lost control over their lives, becoming mindless slaves to stimuli much like the cops who stopped at red lights even when it made no sense.

But it wasn’t just Japan. Luigi believed people everywhere were becoming NPCs, increasingly living their lives as a series of reflex reactions rather than consciously choosing their behaviours. The West was following closely behind Japan, driven by tech companies intent on mesmerising us into servile consumers. Luigi feared that once we’d surrendered our agency, we’d surrender everything else.

Unlike most people who decry others as NPCs, Luigi showed enough awareness to identify that he, too, lived much of his life on autopilot, confessing that he sometimes wasted whole afternoons doomscrolling social media. He said he wanted to regain some of the agency he felt he had lost to online distractions, so we spent much of the chat discussing ways he could become more agentic.

Along with discussing how my favourite philosophy, Stoicism, could teach him to live more deliberately, I also suggested to Luigi that he should avoid automating tasks, which led us to discuss my essay about gamification.

Luigi had much to say about this essay, not least because it involves the story of the Unabomber, Ted Kaczynski, who shared his belief that modern life is taking away people’s agency. I made it clear that, while I agreed with some of what Kaczynski had written in his manifesto, I found his acts of terrorism abhorrent. Luigi agreed, saying something along the lines of: “he deserved to be taken seriously, but he also deserved to be in jail.”

Besides Kaczynski, Luigi’s intellectual tastes were relatively normal. Writers he spoke fondly of included Tim Urban, Sam Harris, Yuval Noah Harari, Jonathan Haidt, and Aldous Huxley. His political views were less conventional. When I asked him if he was voting in the presidential election, he scrunched his nose and said he wasn’t crazy about Trump or Biden, but liked some of the things RFK Jr. was saying. I regard RFK Jr. as a crank who regularly pushes harmful pseudoscience, but I didn’t mention it so as not to derail the conversation.

Somehow, from there we ended up talking about intergenerational trauma, and it was here that we had our only significant disagreement. Luigi implied that he believed trauma could be directly inherited and accumulated in families much like generational wealth. He claimed to have based this view partly on his own personal experiences. It sounded to me like he was describing a pseudoscientific misinterpretation of epigenetics, popularised by activist-academics and books like The Body Keeps the Score.

The idea that trauma is passed down epigenetically is not only unscientific, but also un-agentic. If you believe your trauma is hardwired into your DNA, you’re prone to passively accept it rather than actively trying to overcome it. And so, in a bid to increase Luigi’s agency, I pointed out, as politely as I could, why he was wrong.

After our chat, I sent Luigi an article debunking epigenetic trauma. He thanked me for the article, and also told me he’d bought me a six-month subscription to a reading app which he believed would help make my job easier.

I have Asperger’s, so I’m a poor judge of social cues. Further, I have liked every subscriber I have had a video-call with, of which I have had many, so I’m probably not very discerning in that regard. But to me Luigi seemed like a particularly nice guy.

It wasn’t just that he had bought me a subscription to an app that he thought might help me. It was also that he frequently expressed concerns about humanity generally. He viewed most people as NPCs who needed to be awakened, but he never came off as arrogant, regarding himself as equally zombielike. His view of society was somewhat pessimistic, but tempered with a sense of humour and a focus on solutions rather than mere complaints. And although he seemed to have some unscientific views, he was always open to other viewpoints, and was willing to be corrected.

We interacted on social media several times afterwards, and each time he seemed as polite and thoughtful as he had been in our chat. As the summer ended, I largely withdrew from social media to focus on my book, so I didn’t notice Luigi had vanished.

And then, a few months later, Brian Thompson was shot dead.

Many people celebrated the murder, mocking the victim and lionising the killer. Some were frustrated about the costs of health insurance or outraged that a loved one had been denied medical claims. For this they blamed Thompson, CEO of America’s largest health insurance company.

But while thousands reacted on social media with laughter emojis to Thompson’s murder, I was sickened. Vigilantism is always wrong. If you celebrate someone gunning down a defenceless person in the street, then you advocate for a world in which this is an acceptable thing for anyone to do. You advocate for a world in which a stranger can decide that you’re also a bad person, and gun you down in the street. In such a world, I promise you, your health insurance would cost much more.

When Luigi was revealed as the suspect, I was bewildered. My mind raced back to our chat, searching for clues that he could have done this. The only salient detail was probably when Luigi briefly mentioned that healthcare in the US was expensive and that we Britons were lucky to have the National Health Service. But this statement alone gave no indication Luigi might have been capable of murder.

When the shock faded and my wits returned, I ceased to be quite so surprised. I have long known that people who are capable of great kindness also tend to be capable of great cruelty, because both extremes are often animated by the same crazed impulsivity. It’s why many of the people celebrating the murder are those who self-identify as “compassionate” Leftists. And it’s why most of history’s greatest evils were committed by people who thought they were doing good.

Much more puzzling than the cruelty, though, was the stupidity. Luigi had seemed intelligent, far too intelligent to do something so dumb. Smart people might be better able to rationalise stupid actions and beliefs, but Luigi’s alleged rationalisation, given in a short “minifesto”, was nowhere near the intellectual standard I would’ve expected of him.

As shown by data blogger Cremieux Recueil, the minifesto gets a lot wrong. It claims that “the US has the #1 most expensive healthcare system in the world, yet we rank roughly #42 in life expectancy”, ignoring the fact that America’s life expectancy has little to do with health insurance and much more to do with Americans being disproportionately obese, violent, and drug-addicted. Further, it makes basic factual errors, such as confusing market cap with revenue. The writer even admits they don’t know what they’re talking about: “I do not pretend to be the most qualified person to lay out the full argument.”

Not only was the justification for the targeting of Brian Thompson stupid, but the targeting itself was stupid. While it’s true that UnitedHealthcare has the highest denial rate for medical claims, the CEO doesn’t set the approval rate — that’s done by the actuaries, who themselves are constrained by various considerations, such as the need to keep costs low, including for policyholders. But even if Thompson did have carte blanche to set his company’s approval rates, it wouldn’t have made a big difference.

“Not only was the justification for the targeting of Brian Thompson stupid, but the targeting itself was stupid.”

Health insurance companies don’t get rich by denying payouts. As the economics blogger Noah Smith points out, UnitedHealthcare’s net profit is about half of the average of S&P 500 companies. According to the Harvard economist David Cutler, even if the United States cut every pharmaceutical price in half and eliminated all profits on health insurance, the gap between US medical spending and that of other rich countries would fall by less than a quarter.

Brian Thompson was a normal, flawed guy trying to keep costs low both for his company and his policyholders, while keeping his duty to shareholders whose investment his company depended on. He was a tiny cog in a vast and unfair system that’s controlled by no single person but by the cumulative actions of millions of people operating in their own immediate interests. Ted Kaczynski called such decentralised problems “self-propagating systems”, recognising that they weren’t the result of human coordination, but rather, a lack of it. If Kaczynski’s bombs and book-length manifesto couldn’t destroy such a system, then Luigi, with his alleged 3D-printed pistol and shoddy minifesto, certainly can’t.

People allocate agency strategically, assigning praise to allies and blame to enemies. Luigi’s supporters misattribute total agency to Thompson so they can scapegoat him for a societal problem he had little control over. Meanwhile, they deny all agency to Luigi, claiming he was pushed by a corrupt system or simple back pain.

But, while they’re wrong about Thompson, they may have a point about Luigi. If he was in extreme pain, or in the grip of mental illness, it would explain why a man who was consistently thoughtful in his interactions with me may have committed a monumentally thoughtless act, rationalised by an equally thoughtless note.

On the other hand, if Luigi was mentally or physically unwell, it’s unlikely he’d have been able to carry out a meticulous assassination and then evade authorities for almost a week while travelling across one of the most surveilled regions on earth.

In my limited interactions with Luigi, I never got the impression he had spinal or mental issues. But I did get the sense he felt alienated. He often decried the lack of social connection in the modern world, and on a couple of occasions he lamented that the people around him were “on a different wavelength” to him.

On 10 June, I received my last communication from Luigi. It was a seemingly innocent request; he wanted me to help him curate his social media feed. I’d already given him tips on how to do that, so the question struck me as odd. Rather than accepting a call, I directed him to a relevant article I’d written and offered to answer any questions he had about it. I never heard from him again.

In retrospect, I wonder if his request was an awkward cry for help, as a New York Times journalist told me it was his last known online communication. It’s hard not to wonder if, had I answered his call, things might have turned out differently.

I don’t know if Luigi ever found the agency he came to me looking for. If he didn’t, I hope he gets the help he needs. But if he did find his agency, well, the price of agency is culpability.

***

A version of this article was first published on The Prism on 22 December 2024.


Gurwinder Bhogal is a freelance writer. His work can be found at gurwinder.substack.com

G_S_Bhogal

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UnHerd Reader
UnHerd Reader
14 days ago

“Health insurance companies don’t get rich by denying payouts”
Really???
I’d love to see proof of this.
At the very least, it’s blatantly obvious that if UnitedHealthcare substantially reduced their claims denial rate – say, to that of the lowest in the industry – it would make a LOT less profit…

Norman Powers
Norman Powers
10 days ago
Reply to  UnHerd Reader

An insurer that started denying every payout tomorrow would be immediately be sued and lose for contract violations, then lose all their customers and go bankrupt.
Insurers do not get rich by arbitrarily denying payouts. They don’t get rich at all really considering their less than stellar profit margins – Gurwinder is correct on this point and many others.
They make some money by doing the correct quantity of denials, which means by denying fraud, useless quack remedies and cases where the cost/benefit analysis is totally wrong.
If you disagree with this basic statement of the obvious then feel free to capture the entire health insurance market by starting up a new insurer that always pays out on every claim automatically.

Last edited 10 days ago by Norman Powers
Ron Ronors
Ron Ronors
15 days ago

“The regime will want you to be bereft of precise information and wallowing in disinformation, lies and conspiracy theories.  
Do not be fooled by this.
They will most likely force news media to comply or even remove alarming stories that could directly impact your life.”

“Writers in newsrooms from The Atlantic, to The New York Times keep putting out dimwitted op-eds reducing Mangione’s violence to meaningless barbarism, failing to engage with the horrifying realities of healthcare in America.”

“I won’t go full conspiracy-theorist (it makes me tired), but some of these pieces come across as paid for by United Healthcare and their subsidiaries.”
https://pastebin.com/KP4nmD5Y

Bret Larson
Bret Larson
13 days ago
Reply to  Ron Ronors

The real villains are the ones suggesting gender realignment as healthcare paid for by society.

Lukasz Gregorczyk
Lukasz Gregorczyk
15 days ago

Not sure why would the author question the veracity of intergenerational trauma , otherwise a good read: https://en.wikipedia.org/wiki/Transgenerational_trauma

Kevin Jones
Kevin Jones
15 days ago

I think he is referring the epigenetic theory of intergenerational trauma, which isn’t really considered credible.

One proposed model suggests that an parents trauma could be inherited through an epigenetic biological mechanism. Although the idea has been widely touted in the media, it is not supported by robust evidence.[112]

Lukasz Gregorczyk
Lukasz Gregorczyk
15 days ago
Reply to  Kevin Jones

Thanks, I thought that the Dutch winter famine legacy gave some strength to this theory.

El Uro
El Uro
15 days ago
Reply to  Kevin Jones

Stalin’s great biologist Lysenko cut off the tails of mice in the hope of breeding a tailless strain. I don’t know if his efforts were successful. It seems like not.

Ethniciodo Rodenydo
Ethniciodo Rodenydo
10 days ago
Reply to  Kevin Jones

Logically it would seem like an evolutionary inevitability. Genetic inheritability seems just too slow.
From what I have seen in my lifetime the trauma of 2 world wars seems to haver left its mark down the generation. Of course there are several mechanisms through this could have happened, but I would not be quick to rule out evolution.

T Bone
T Bone
15 days ago

Identity Politics is the idea that people should be seen not as individuals but as members of an oppressed, marginalized class. The concept of “Intergenerational Trauma” treats the group as one and reinforces that group members are an “excluded other.”

This bleeds into the Western Marxist concept of Structural Determinism that claims opportunities for marginalized group members are mostly predetermined. This encourages both resentment and learned helplessness which leads to apathy and exacerbates existing group disparities. It’s a self-reinforcing cycle that discourages integration and promotes divisive balkanization through the promotion of Identarianism.

Lukasz Gregorczyk
Lukasz Gregorczyk
15 days ago
Reply to  T Bone

Sure, and I am just pointing out that people affected by the Dutch winter famine had gene expression alterations that affected their metabolism. These were established in utero and were passed on to generations that followed. These changes are considered epigenetic because they were triggered environmentally. I had no idea that such findings were used to peddle identity politics later on, but this is no the point I was trying to make.

T Bone
T Bone
14 days ago

I glanced at the conclusions of study. I didn’t read the whole study so correct me if I’m wrong but it doesn’t look like the study was intergenerational. The study contrasted those exposed to certain famine conditions in utero vs those who did not.

My point is that it’s not clear if the gene mutations passed on. I recall a few documentaries about how biolife outside Chernobyl has almost completely rebounded. This after all the mutations in the first generation.

Further let’s add that the famine and nuclear meltdown were acute concrete and traceable exposures. The conditions were literally polluted. Whats being described/refuted by the author here is that “intergenerational trauma epigenetics” is a theory that because groups were treated very poorly in the past, they might have some kind of stress related mutation due to poor treatment that can’t be overcome. Its a theory of environmental determinism, IE scientific racism.

UnHerd Reader
UnHerd Reader
14 days ago
Reply to  T Bone

Most genetic mutations are recessive. Therefore, they are unlikely to be passed on generation to generation.

Lukasz Gregorczyk
Lukasz Gregorczyk
14 days ago
Reply to  T Bone

Thanks for clarifying. I agree that to turn this theory into some kind of a social justice stick with undisputed causality is wrong.
Here are some findings on the inter generational effects of famine:

Environmental Science, Medicine
BJOG: an International Journal of Obstetrics and…
2013

“It is found that maternal under‐nutrition during gestation is associated with increased metabolic and cardiovascular disease in the offspring and increased neonatal adiposity among the grandchildren of women who had been undernourished during pregnancy…”

But also let’s consider the hormetic principle as it may also play a part:
https://en.m.wikipedia.org/wiki/Hormesis

glyn harries
glyn harries
14 days ago
Reply to  T Bone

This, “Identity Politics is the idea that people should be seen not as individuals but as members of an oppressed, marginalized class.” is completely wrong. Identity politics gets people to identify themselves as a individuals oppressed for any number of competing reasons. What it does not do is get people to think of themselves as a class. Which is why Identity Politics is the antithesis of Marxism, which argues people, however they identify, are in classes based on their position under capitalism.

T Bone
T Bone
14 days ago
Reply to  glyn harries

It’s an inverted principle of “Orthodox” Marxism but the identity group operates exactly like a new proletariat.

Marxism itself is constantly inverting the Base/Superstructure in a dialectical spiral or mutating, whatever you want to call it. The group is always changing but the foundational Victim/Oppressor Manichean Lens is constant.

It has to taxonomize people into groups and the interests of individuals in the group is always secondary to group interests. Group interests are then always defined by “Experts” with knowledge of how invisible structures of oppression operate. In order to preserve group solidarity, experts have to assure certain “truths” are codified into a Narrative structure about group oppression that can’t be challenged (Dogma).

That’s how you know there’s continuity of Marxism. The operative structure remains the same even while new groups replace the old and new theories are trotted out.

Andrew Vanbarner
Andrew Vanbarner
14 days ago
Reply to  glyn harries

You are at best confusing Marxism with neo-Marxism.
Both involve material dialectics, both are opposed to liberal democracy, and are in fact antidemocratic, both require an authoritarian and often totalitarian state, and both are destructive, divisive, and nonsensical.
The Neo-Marxism of so called “anti-racism” can more or less plausibly be adopted by the rich, as it is in wealthy, western countries. That’s the only difference, though it’s also true that Marx survived only because of the generosity of the Engels family.

Vesselina Zaitzeva
Vesselina Zaitzeva
14 days ago
Reply to  T Bone

Thank you for this detailed and analytical post. I have posted a comment along these lines before reading yours, but mine is definitely rather sketchy and not at all as well-founded as yours!

Vesselina Zaitzeva
Vesselina Zaitzeva
14 days ago

Oh please, let’s not cite Wikipedia as a credible source! It is not.
There is not a single reliable piece of research proving the existence of intergenerational trauma.
This concept is mostly used for propaganda purposes, like justifying the need for reparations to be paid to Black Americans who suffer from ‘intergeneraional trauma’ because some of their predecessors were slaves.

Ron Ronors
Ron Ronors
15 days ago

Cowards, all. “Find out just what any people will quietly submit to and you have found out the exact measure of injustice and wrong which will be imposed upon them.” – Frederick Douglass, 1857.
https://pastebin.com/KP4nmD5Y

Ron Ronors
Ron Ronors
14 days ago

Pope should canonize Luigi:
https://www.merriam-webster.com/dictionary/canonize

Nobel Peace Prize-nomination is also well-deserved.
For the civil war-preventive solution, to American trolley problem: https://philosophics.blog/2024/12/10/the-trolley-problem-of-for-profit-healthcare

Was this the most rational assassination in American history?
As someone who has been cursing MAGAs for the last six years, I’ve decided to change my ways based on current events. I no longer care if you’re a Bernie progressive or a MAGA Republican. My friends, family, and I will no longer judge anyone based on their political views, as long as we agree on one thing: CEOs are the cause of 99% of the inequality and devastation in our world—not everyday Republicans, Democrats, or people of any political belief.
And so red vs blue dies here. I hope. It’s not me vs my neighbours, it is us vs the oligarchs.
Acceleration” of the greediest billionaire-tyrants, is the ‘message’ imposed upon flawed, tiktok-naive democracies.
From the strict title: “Teacher of the nations”:
This is a fascinating essay on two thinkers (Chinese and British) whose goal was to help Western capitalism destroy itself, and how the CCP may now see TikTok as a way to do that.
…by turning everything into a product, Western capitalism devours every aspect of American culture, including the traditions that bind it together as a nation, leading to atomization and polarization.
This view, that the current system must be accelerated to be transformed, has since become known as ‘accelerationism.’
…acceleration is not just a destructive force but also a creative one; all democracies accelerate toward ruin, but an undemocratic system — run by elites unfettered by the concerns of the masses — could accelerate a country to prosperity.
So, can democracy in time stop election-rigging billionaire environmental polluters?
TikTok, along with 58 other Chinese-created apps, was banned completely in India by the Ministry of Electronics and Information Technology on 29 June 2020, with a statement saying they were ‘prejudicial to the sovereignty and integrity of India, defense of India, security of state, and public order‘”

Or, should the accelerationism-lesson be allowed to continue, until all people on our earth face the same injustice as Luigi? https://pastebin.com/KP4nmD5Y

Benjamin Greco
Benjamin Greco
11 days ago

Of course, trauma is not passed down, but behaviors are.

Karl Juhnke
Karl Juhnke
9 days ago

When CEOs of Health Insurance Companies meet with shareholders, board members etc and celebrate increased profits from legalised atrocities in the form of preventable pain, suffering and death, they are in effect knowingly applauding pain, suffering and deaths. One CEO was illegally killed compared to how many customers legally harmed and killed? And you want to talk of agency?

Philip Hanna
Philip Hanna
15 days ago

I suspect he knew that the CEO wasn’t necessarily the person responsible, but I don’t think murdering a random actuary would have drawn quite the same response. He clearly wanted to be noticed as a man of action, or agency, above anything else. Now he gets to posture himself as some weird freedom fighter until everyone forgets about him, then spend the rest of his life in a jail cell. What a dope.

Bret Larson
Bret Larson
15 days ago
Reply to  Philip Hanna

You mean noticed as a terrorist?

Christopher Barclay
Christopher Barclay
15 days ago
Reply to  Philip Hanna

A ‘random actuary’ at United Healthcare probably makes about what he or she would make at any other company. Thompson in contrast made $10m p.a. That is why in Mangione’s eyes he was the symbol of an abusive industry.

Andrew Vanbarner
Andrew Vanbarner
15 days ago

I worked as an actuary at Blue Cross. For the level of difficulty involved, the salaries were low, and I now make nearly three times as much in software.
I didn’t much care for working in that sector – insurers in general, much like banks, tend to be dreary, stultifying workplaces, with fairly low starting salaries and less than collegial environments.
Our CEO made an upper middle to nearly upper class income, as did a few other very senior executives, but I saw at best newer BMWs or Mercedes in the parking ramp, not Ferraris. (An older actuary had a well used and not particularly valuable Aston Martin that he serviced himself, which was the only notable car I saw. I believe his wife had a well paid job, also.)
All insurers, including the reinsurers who insure companies against large losses, are at bottom investment management firms.
Most years, we had an underwriting profit (premiums minus claims and expenses) of negative one or two percent, with investment gains of three or four percent keeping the lights on.
Health insurers (including ours, which was a non-profit, meaning zero shareholders raising capital for us) can survive a bad stock and bond market, but not forever. We had very aggressive competitors, an older, often unhealthy group of insureds to cover, and we were located in a post industrial, “rust belt” city.
However, eighty percent of our claims were paid electronically, with zero human interaction. Twenty percent involved some sort of human intervention, and were most often some sort of clerical error.
Amounts we paid to providers were negotiated using the “Medicare multiple,” meaning we’d pay two to four times what Medicare would pay. Under “Medicare for All,” many if not most of our providers – hospitals, clinics, medical practices – would be forced to close. Private insurers heavily subsidize government payors, are heavily taxed, and are very heavily regulated.
I suppose back then I was part of the “bloat.” But my job would be impossible to automate, using even today’s technology, and I often found missing revenue, or doubly insured claimants, or wildly expensive claimants. I made about $50,000 a year, which at the time was a middle class salary, but barely so.
High cost claimants drive health care costs. They often have little money, or not enough money to cover their care. They’re often elderly, or working class, or uninsured, or are the sorts of people who regularly have accidents and mishaps that somehow elude the rest of us.
I’ve seen fertility clinics and neo-natal wards submit claims high enough to buy a brand new car, often followed by eye watering NICU claims. I’ve seen claims for hemophilia treatments, for one patient, in the millions, and I’ve seen radiology or imaging claims that launch their practitioners into millionaire status. Our litigious society also encourages defensive medicine, and many of our legislators were formerly plaintiff’s attorneys. It’s not insurance firms growing rich, or at least they’re not the only ones profiting.
It would be wonderful if there was an unlimited supply of money to care for everyone. There isn’t. Claims are denied by government payors all the time, even when a society has double digit sales taxes and fifty percent income taxes, as France and other countries have.
American health care is peculiar, yes. We are fatter, older, more violent, and more hedonistic than other societies, yes. We have a largely market based economy, in a very diverse and very open society, and we largely protect the ability of individuals to express their opinions, no matter how wrong. These last three things are partly why we’re so dazzlingly wealthy.
We also invented or heavily contributed to modern medicine’s use of lasers, genetic therapy, transplant surgery, modern pharmaceuticals, and countless other life saving innovations.

Alex Lekas
Alex Lekas
14 days ago

We’re also populated by people who 1) have no clue about the sausage making you outlined and 2) often take zero responsibility for the results of stupid decisions.

Vesselina Zaitzeva
Vesselina Zaitzeva
14 days ago

Thank you, Andrew, for this very interesting and eye-opening post!
It reminded me how about 15 years ago I was referred to be scanned by some hghly specialised equipment for analysing eye conditions.
This equipment was operated by a very young and very enthusiastic doctor who told me that this was the only such apparatus in the entire Benelux (!), while in the US it was something completely normal and available in every more-or-less big hospital.
This Belgian doctor managed to have this equipment supplied to Belgium because he was studying for his PhD in the USA and he convinced a US charity to donate this equipment to Belgium. The condition was that this equipment should be installed in a clinic for low-income people (while being also available to patients referred to scanning). I think that another condition was that this doctor would use the equipment for the purposes of his PhD and further research.
It was one of those moments when I clearly realised how much ahead the US healthcare is of healthcare in Europe, even in such rich countries as Belgium, Luxembourg and the Netherlands…

Steve Jolly
Steve Jolly
14 days ago

Americans shouldn’t, and most don’t, hold individual employees of insurance companies personally responsible for the problems in the healthcare industry. Mr. Thompson was a more or less innocent victim, who committed no legal crime and whose only moral offense was to work for a system that many, including myself, consider to be a priori bad, dysfunctional, or undesirable due to the basic nature of what it does and the built in incentives that it creates. I cannot dispute your firsthand knowledge of the situation inside an insurance company or your firsthand experience. I suspect it is accurate, and also irrelevant. I do not assign responsibility to individual employees of individual insurance companies for creating this ridiculous, untenable system. Nor do I assign responsibility to the patients or provider in said healthcare system as you seem to imply as that is equally unreasonable. That is Mr. Mangione’s error, to assign personal responsibility to people participating in the system rather than the system itself. It is possible to have a system that is entirely bad for society and yet no individual is responsible for creating the situation.

With respect, insurance companies should not exist. They do not provide healthcare nor do they consume it. They are neither supply, nor demand. They are, at best facilitators who simply move money around to facilitate other economic activities, and at worst, parasites that sustain themselves by attaching themselves to another industry and feeding on the economic transactions of these of other industries through economic rent-seeking. Whether their profits are obscenely large or appropriately humble makes no difference. Whatever revenues exist and whatever costs are subtracted from those revenues to arrive at the overall profits, whether large or small, are all pure waste from a macroeconomic standpoint because they aren’t going to increase the supply of healthcare, or lower costs, or automate or innovate or do anything else to lower the costs or raise the standards of care. All of those little everyday activities that for-profit companies make on a daily basis to lower costs, increase efficiency, and distinguish themselves from their competition are simply absent. After decades of this lack of free market incentives, the losses in efficiency have mounted to a truly ridiculous level. You mention, correctly, that prices for services are negotiated with the government and insurance companies, which creates incentives for providers to exaggerate costs as much as possible in such negotiations. It also creates an incentive for providers to oversupply. If they buy a new MRI machine, they will find any excuse to use it however thin. This operates in concert with the practice of ‘defensive’ medicine that you mention. Note that the actual necessity or utility of various cost decisions is several times removed from actual consumer demand. The hospital need not consider the price another hospital in a neighboring town is charging. The consumer need only check whether the provider is in or out of network. When cost and spending decisions and the consequences thereof are moved from the providers and consumers to someone else, the basic market forces that make everything from smart phones to gasoline to bread more affordable cannot work. It’s the incentives that are the problem. It’s the lack of market forces that are the problem.

For the record, I don’t favor medicare for all. It strikes me as a reshuffling of deck chairs on a rapidly sinking ships. I rather suspect our incompetent politicians and dismissive elites would simply outsource medicare for all to the same insurance conglomerates and pretend they actually fixed something when in reality they didn’t even make an attempt. Even if the system was truly overhauled, I’ve seen enough rants about the NHS on this site to know that nationalized health care has its own set of problems, and a nationalized system will address the lack of market forces and basic economic incentives to lower cost. A slightly better model might be making healthcare providers quasi-public institutions in a fashion similar to other public utilities where local governments create companies and cooperatives partially funded by public revenues to contract with for-profit providers to provision an area with healthcare. Such a system would restrict access based on geography but would at least create some competition and incentive for providers to lower costs to appeal to the local governments who would be the primary consumers. Waste management works like this. The town usually pays some company to provide for trash disposal and they tend to choose a provider that fits the needs and desires of local voters and meets their standards at the lowest possible costs. It would also allow for state governments and the federal government to make provisions and pass laws for poorer areas to compensate for areas with limited local tax revenue. This might be something that could be implemented in national legislation which would then pass the authority for the operational details to the individual states. In general, the delegation of powers to states is a good thing as it allows many possible solutions at the state level to compete with one another. Successful policies can be copied and failures can be rejected. The government could also just fund it’s own minimum standards based healthcare system without restricting the right of private enterprise to establish their own for-profit systems with higher standards of care. It’s hard to compete with free, so the higher quality systems would still have a great incentive to limit costs and charge a low enough price to get enough customers to fill their capacity and maximize their revenue. Excuses notwithstanding, alternatives do exist. Citizens need not support the continuation of an inefficient system with warped incentives that raises the price of basic services for all and redirects much of the revenue to companies who neither provide nor consume the actual product. Even if the overall standard of care is better than elsewhere, the people have a right to demand better.

Andrew Vanbarner
Andrew Vanbarner
14 days ago
Reply to  Steve Jolly

Perhaps, but what would those alternatives be, precisely?
Your choices are essentially limited to either very high taxes, which cause economic inefficiencies that are often worse, or expensive workplace benefits that the poor are unable to access.
The old and the sick deserve some sort of care. Who will pay for it? Most people in need of very expensive treatment have no way of paying for it, and yet someone else must.
All countries ration care. All countries spend large sums of money on patients and providers, if they’re to have health care at all. Nothing can be solved by the swipe of a legislator’s pen, and certainly only great harm is done by an assassin’s bullet.
There are no simple answers – only very difficult choices.

Dennis Roberts
Dennis Roberts
14 days ago

It’s really quite odd that the author doesn’t make this very obvious point.

Steve Jolly
Steve Jolly
14 days ago
Reply to  Philip Hanna

A dope? Perhaps, but not necessarily. At least now he won’t have to pay for his health care. Prisoners convicted of crimes must be provided a minimum standard of health care. It has often been said that a society may be judged by how they treat their prisoners, and if this is true, there can be few societies in history as compassionate and generous as the USA of the present. The point I’m making is this. If one is in sufficient physical pain and cannot afford the medications to suppress said pain, then committing a heinous crime and being imprisoned is, in some sense, a rational decision; selfish yes, but rational. The task then becomes what crime to commit, and it makes a certain amount of sense to choose a crime that symbolizes or draws attention to his particular problem. Perhaps this is not the last we will hear from Luigi Mangione and he will make this very point himself in his trial or in some future media interview. I have dismissed his actions as those of a serial killer who happened to be caught early, but then perhaps I underestimated him. The author seems to believe Mr. Mangione to be an intelligent person, so perhaps he’s intelligent enough to use his public fame to continue to draw attention to his cause by writing and describing his experience in the prison system, including the care he receives. The US healthcare system’s routine decision to deny coverage to this young man may yet end up being more costly than their actuarial books can measure. I will have little sympathy for them. Companies are not individuals and thus not worthy of human sympathy to begin with, but they are worthy of the consequences of their actions, intended or otherwise. The law of unintended consequences humbles us all.

Chipoko
Chipoko
14 days ago
Reply to  Philip Hanna

He’s not a “dope” – he’s a cold-blooded murderer. Upon convicted he should be executed and not cost the public purse huge sums of money keeping him alive in prison for the rest of his life.

David Morley
David Morley
15 days ago

The problem is that there is not a lot here to distinguish him from a pretty large number of disaffected people. We still don’t know why he chose to act on his beliefs and theories while others simply don’t.

I did wonder if there was more than a hint of narcissism about him – but it’s little more than speculation.

Andrew Vanbarner
Andrew Vanbarner
14 days ago
Reply to  David Morley

A gym honed Ivy League grad would likely have a very positive self- image, which if combined with a social media obsession or some sort of mental health crisis could curdle into narcissism and psychopathy.
And could serve to justify, to himself, shooting an innocent person in the back.

j watson
j watson
15 days ago

Whatever drove Mangione I’d argue the key deciding factor was the ease of being able to own a Gun and thus be in the position to carry out whatever was going through his head at the time. It would just be much more difficult in the UK. It’s not an excuse for him. He’s a murderer. But you give people the opportunity to walk around with firearms this sort of thing going to happen because there’s alot messed up people who might do something without thought…until too late. It doesn’t take many.
Slightly separate point – Author makes case nobody to blame for way healthcare costs can cripple individuals in the US and that CEO was just doing the best job poss in difficult circumstances. I suspect Author correct about the CEO, but the US has made explicit decision to run healthcare like this. Repeatedly more fundamental change been blocked, most often by the Republican Right.
Author also mentions the costs ‘…are so high because of administrative inefficiencies’ – well you build in a whole private insurance market where the cost can be passed on and incentive to focus on exclusions and small print and you end up with an administrative cost per capita massively higher than NHS equivalent. It’s a reminder.

Alex Lekas
Alex Lekas
14 days ago
Reply to  j watson

People walk around with firearms all the time and somehow manage to avoid committing homicide. And cost inefficiencies were the result of private markets, the NHS and systems like it would be flush with cash.

j watson
j watson
13 days ago
Reply to  Alex Lekas

Re: firearms – indeed but it doesn’t take many does it AL. We don’t have that in UK. US had almost 14k firearm murders last year. So much about US is jaw dropping brilliant, but on Guns us Brits will always think US been jaw droppingly stupid.
I didn’t quite follow your 2nd point, but I think you are concurring healthcare private markets don’t work well. Unsurprising as the information is v asymmetric between customer and provider.

T Bone
T Bone
14 days ago
Reply to  j watson

How’d he get the gun dear Watson? Read the specifics and then comment

j watson
j watson
13 days ago
Reply to  T Bone

Easier than he would in the UK and that’s enough.

Kat Kazak
Kat Kazak
14 days ago

There’s something very Decembrist, or Bruce Wayne if you will, about Mangione. The Decembrists were all aristocracy and heirs to vast estates with thousands of serfs, their desire to see all the country’s serfs liberated and a constitution passed could have been accomplished in many, many ways – they could’ve liberated their serfs, setting an example, or appealed directly with the emperor to pass reforms, instead they chose to revolt on the day of his coronation. Little surprise then that the emperor Nicholas I took it rather poorly and doled out some rather severe punishments, setting the tone for his entire over-policed reign.
Bruce Wayne is the establishment, he can open clinics, fund and update the police force, get elected, and lobby on behalf of his city. Instead he dons a cape and goes out in the night, fighting one criminal at a time. Hardly an institution that can be a solid foundation for future security and prosperity, is it?
The Decembrists, Bruce Wayne and Mangione all had the privilege of being elevated above the misery of the masses and all had the heart to wish to make the world better for those deprived, but they were also all in the position to enact real institutional change… And instead they did this?
Let’s say Mangione hates the healthcare system in the US, fair enough, it is objectively horrible.
He has wealth and education and ideas and ideals. Is it not better to use all of that to lobby for a national health service or at least for regulation? People in the Netherlands pay for health insurance and somehow, magically, it works and it’s free at point of use, which means a dual payment healthcare system can work as intended and it need not be a miserable experience for all involved.
Killing a CEO just means the next one will specify he needs a protective detail in his contract.
What a sad waste of potential.

glyn harries
glyn harries
14 days ago
Reply to  Kat Kazak

Mangione doesn’t seem to have been super wealthy. His grandad was a poor Italian migrant who did well. Not old money at all. And the Ivy League college seems to have been his local college. So I suspect less agency let alone power than you are attributing him.

Andrew Vanbarner
Andrew Vanbarner
14 days ago
Reply to  glyn harries

His family reportedly had large real estate holdings that included nursing homes, resorts, and commercial properties.
U of Penn is one of the top universities in the country – the Wharton Business School is ranked next to Harvard Business School and Yale – and Luigi himself was well traveled and gainfully employed. A lucrative career in tech or engineering awaited him.
He’s not the fair haired scion of a WASP banking family, but he’s hardly the son of humble immigrants.

John Dewhirst
John Dewhirst
11 days ago

Wow.

Janet Baker
Janet Baker
11 days ago

Luigi Mangione turned to a man like Gurwinder Bhogal for help, and what he got was all Bhogal and men like Bhogal, seculars, materialists, has to offer, advice on how to curate his anguish. Luigi needs a priest with all the resources Christianity brings to these basic human questions. Not only suffering, but even about how to deliver healthcare, a functioning non-profit system overthrown, alas, five hundred years ago.

Jim Veenbaas
Jim Veenbaas
15 days ago

I find it interesting that he believed in intergenerational trauma. This would make him the ultimate NPC – a man with no agency.

Vesselina Zaitzeva
Vesselina Zaitzeva
14 days ago
Reply to  Jim Veenbaas

I think that this belief is also typical of people with narcissistic personality disorder.
And you’re right about the lack of agency leading to believing in intergenerational trauma. But this belief also allows people to avoid responsibility and to feel victimised (both lack of agency, but also characteristic of narcissism.)

Christopher Barclay
Christopher Barclay
15 days ago

Didn’t Prince Harry also believe in epigenetic trauma? If I was his brother or Dad, I would double their protection or hopefully just ban him from returning to the UK.

Ben R
Ben R
14 days ago

Yes, but while Luigi is, by all accounts, highly intelligent and well read, Prince Harry is functionally illiterate.

Vesselina Zaitzeva
Vesselina Zaitzeva
14 days ago

Given the influence his wife has on him, I would not be surprised to learn that he also believes in astrology, chamanism, and Taro…

Vesselina Zaitzeva
Vesselina Zaitzeva
14 days ago

A brilliant, insightful, and deep article!
Empathetic and considerate, without justifying unjustifiable.
Thank you so much!

Maria Caprile
Maria Caprile
10 days ago

Thanks a lot for this article. Best I have read on this topic.

Satyam Nagwekar
Satyam Nagwekar
10 days ago

Finally, some really good insights on an Unherd article. I may not agree with all of what Gurwinder says but still a nice read.

Michael Lipkin
Michael Lipkin
15 days ago

Raskolnikov!
Great article in Quillette

David Morley
David Morley
15 days ago
Reply to  Michael Lipkin

I think a lot of people’s minds turned to Dostoevsky when this happened.

UnHerd Reader
UnHerd Reader
15 days ago

Thoughtful, well written, and brilliant. Thank you.

Bret Larson
Bret Larson
15 days ago
Reply to  UnHerd Reader

Hm, I stopped reading at “bright young man” dim young man would be more apt.

Tyler Durden
Tyler Durden
9 days ago

Another appalling Maoist, and a murderous one too, who speaks for his dismal generation in attacking the free market spirit of the United States.