Luigi Mangione and the American way of death

The musical was first performed in June in a 50-seat venue in San Francisco and was described by a local arts journalist as a “wickedly funny, whip-smart comedy” that was “clearly destined for bigger, buzzier stages”.

In the musical, Mangione is sharing a cell with crypto-fraudster Sam Bankman-Fried and sex criminal P. Diddy [Sean Combs]. The same journalist goes on to praise the actor playing Mangione as “oozing Italian charm and sex appeal, slipping in a slow, subtle striptease mid-song”. He may be a killer but the guy has charisma.

The object of the show may be satirical but not everyone in the first night audience quite got the joke. A local TV reporter interviewed two young play-goers. “The whole Luigi unfolding has been something that is really compelling,” said one, “I think a lot of people support him and what better way to honour him and what’s happening by putting it into a musical?”

Her friend agreed. “The most important thing is knowing just how many people support him even if he did do it. It shows just how dire the situation actually is, that the healthcare system is broken and people would be willing to prop up somebody that would potentially resort to violence in order to help fix a system that is hurting so many people.”

The support is real. One measure of it is that, since his arrest, Luigi merch has become ubiquitous, despite attempts by Amazon and other online outlets to close it down. A vile pink heart studded T-shirt with Mangione’s face on it tells the world “But daddy, I love him!” Another proclaims “Luigi The Man The Myth The Legend”. The most used head-and-shoulders of Mangione – also to be found as a mural in London’s Bethnal Green – has been incorporated into a religious robe and halo outfit, conferring sainthood on the young man from Maryland, who in reality is as much Italian as I am Lithuanian.

Shortly after he was apprehended, polls in the US showed that Americans split two to one as “unfavourable” to Mangione, but there was a significant age factor, with over 40% of 18-29 year olds describing his (alleged) actions as “acceptable” and just under half of college students believing the killing to be “justified”. Only among the over-65s was there overwhelming condemnation.

There has been no polling that I can find outside the US, but friends with twentysomething children report a toleration of the murder, based on a surprising empathy with the predicament of people an ocean away who face the behaviour of a health insurance system that our children have never experienced.

And a total lack of empathy with the victim. Brian Thompson may have been a wealthy executive – he apparently earned $10m in 2023 as chief executive of United Healthcare – but he was also a husband, a father of two, who had led government health programmes in the past, and those who knew him seemed to like him and regard him as a perfectly amiable man. Thompson wasn’t young and broodingly photogenic like Mangione – Jesse Plemons to Ben Whishaw maybe – but he had a life and wasn’t a war criminal. How could you believe he deserved to die?

Luigi Mangione, 26 at the time of the shooting, saw himself as a victim of a system of healthcare that allowed companies to make vast profits from the suffering of citizens – either by making necessary treatment too expensive to afford or by involving patients in an insurance system that maximised its profits by delaying or denying claims.

Mangione had suffered for 18 months from the debilitating spinal condition, spondylolisthesis, which eventually required lumbar fusion surgery. From his own various accounts of his treatment it seems that Mangione felt forced to exaggerate the effects of his condition to eventually qualify for an insurance pay-out on surgery that could cost between $50,000 and $150,000 (by way of comparison, private treatment in the UK might typically cost a third as much).

Wrangles with insurers are the stuff of everyday American lives. Regulation of for-profit insurers is much looser than in Europe and companies have more freedom to define what is or isn’t a “medical necessity”. Nor are they regarded as part of a system where the objective is to offer maximum reasonable care to all citizens. Instead they strike a profit-maximising balance between avoiding liability for, or paying out on too many expensive claims, and appearing so niggardly that employers or individuals refuse to take out insurance with them.

The reluctance on the part of insurers may well be exacerbated by the obvious self-interest doctors have in prescribing expensive treatment.

Many Americans express satisfaction with the way the system has worked for them; US medical treatment when it’s good is very, very good. But the system creates many for whom illness may not just be a physical problem, but a financial disaster. Even where they hold down a job that does come with a much coveted insurance plan, they may find themselves battling with the insurance company over whether even an acute condition is covered. A quick search turns up many cases of patients with similar problems to Mangione’s having to resort to the law to force recalcitrant insurers to pay out.

When Mangione was arrested in Altoona, Pennsylvania 240 miles away from where Thompson was murdered, he was carrying a page of notes, consisting of 262 words and immediately labelled by the media as being his “manifesto”. We don’t have the exact text, but some lines have been reproduced verbatim. Mangione had written: “Frankly, these parasites simply had it coming. A reminder: the US has the #1 most expensive healthcare system… yet we rank roughly #42 in life expectancy.”

“United is the largest company in the US by market cap behind only Apple, Google, Walmart... [Insurers] have simply gotten too powerful, and they continue to abuse our country for immense profit because the American public has allowed them to get away with it.”

Whatever else he may be, Mangione was no swivel-eyed conspiracist and his stats were pretty much correct. Nor were his arguments coming from way out on the left field. His notes cited two authorities, the radical film-maker Michael Moore whose 2007 documentary about the US healthcare system Sicko was nominated for an Oscar, and Dr Elisabeth Rosenthal, a physician turned journalist. Her book An American Sickness: How Healthcare Became Big Business and How You Can Take It Back was published in 2017.

It took aim at the perverse incentives in the US healthcare system that had resulted in the paradox noted by Mangione of high cost and poor results. “The system is not built to help patients,” Rosenthal concluded, “it is built to generate revenue.” Not least for the insurance companies who “routinely deny claims for care that patients thought was guaranteed – and patients rarely have the resources to fight back”.

Rosenthal was in many ways telling Americans what they already thought they knew. A Gallup poll of November 2023 had 70% of respondents agreeing with the statement that the US healthcare system was either “in crisis” or suffering from “major problems”. Another survey showed just 25% with a favourable view of insurance companies.

Some critics of Rosenthal’s influential book rated her as being more convincing on the “how healthcare became big business” part of her argument than on the “how you can take it back” bit. Her suggestions were seen as incremental and insufficiently radical [though they seem pretty sensible to me]. But nowhere did she suggest that killing health insurance executives might be part of a viable reform strategy.

That Mangione should imagine that such an act might be both effective and moral, and that so many young Americans might sympathise with him, is worrying and needs explaining, not least since we are now in the immediate backwash of yet another assassination carried out by a young man, like Mangione from an ordinary, middle-class, suburban background.

Mangione’s strange folk-hero status has plenty of parallels in the past; you only have to think of the legends of Jesse James, Billy the Kid or Ned Kelly, whose freedom from the (often harsh) constraints of 19th-century frontier life can seem somehow attractive. In the late 1960s (a time of energetic student protest in the US and Europe) the historian Eric Hobsbawm published two books sympathetically examining the actions of bandits and lawbreakers.

One, Captain Swing, co-written with George Rudé, looked at the agrarian riots of the 1830s in which landowners and farmers in the southeast of England were threatened on behalf of exploited agricultural labourers, their hayricks burned and their threshing machines destroyed.

The other, Bandits, covered the careers of several outlaws, from Pancho Villa in Mexico to Stenka Razin in Russia, and also the legend of Robin Hood. Hobsbawm labelled these figures “social bandits” since their actions – often pretty murderous – arose from social grievances, and saw them conferred with semi-heroic status by a section of society. They were the “fight-back”, doing the things that many people might have wanted to do, had they the audacity or the courage.

So Mangione might be seen as Rosenthal’s instrument of action. That’s certainly how he saw himself. As he wrote in his notes, “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.”

His bullets took the place of extended argument or vain attempts to win voters to a set of essential reforms. As appears to be the current fashion for killers, the shell cases were inscribed with messages. In Mangione’s case, the words “delay”, “deny” and “depose” had been scratched on them, an allusion to a deeply cynical phrase apparently used in the insurance industry:“Delay, Deny, Defend.”

The romantic appeal is there, if you can somehow forget just how sinister that CCTV footage of the shooting of Brian Thompson actually is. A hooded man steps from the shadows and guns down another. And while you might be the hooded man, you might just as easily be his victim, mightn’t you? And yet Thompson is denied all empathy.

In February’s edition of The Progressive magazine – founded in 1909 and published out of Madison Wisconsin – the writer and podcaster Sarah Jaffe examined the appeal of Mangione to American youth. No teen rube herself (she is 45 and an established author) Jaffe argued that Mangione was admired because he was effective. “The usual response, American style,” she wrote, “might have been to shoot up a call center. But the successful precision targeting of a CEO seems to have struck a chord because, well, it worked.”

“It worked”? I would love to ask Jaffe how did it work? Did it serve as a template for the assassination of Charlie Kirk in Utah? An assassination which, if it has worked, seems to have worked best for the other side? Did it serve as a bloody aide memoire to insurance chief executives to drastically alter company policies? Or will it have “raised the issue” in such a way as to lead to voters opting for leaders who promise radical change?

Jaffe’s chilling answer though, may be found later in her piece when she asks, “will we see more attempts on the lives of CEOs? School shootings, after all, didn’t immediately proliferate but have increased steadily in the years after Columbine until 2024, when there were 971 of them, including 112 that resulted in injury or death.”

This is imagining assassination as a model, not a horrific outlier. And it would be happening because, according to Jaffe, “there is a deep well of anger and pain in the United States, and across the world, and a good number of those angry and hurting people know quite well who is causing their pain”.

It may be that you have to have a limited experience of life not to realise that violence really does beget violence, that for someone else you may be the villain, and that if you can do it to them then they can do it to you. For the moment, to those of us outside looking in, it all seems part of the Trump era; the era of the modern American death wish.

Photograph by Spencer Platt/Getty