About two weeks ago, I wrote a long post here on the killing of UnitedHealthCare (UHC) CEO Brian Thompson. Here’s a follow up. 

Debate continues on the widespread adulation for Luigi Mangione, Thompson’s presumptive assassin. As I’ve previously suggested, I regard much of this debate as misframed. The main issue, as I see it, is whether Thompson had done anything to justify Mangione’s killing him. That issue mostly depends on whether and in what sense Thompson was guilty of a form of wrongful killing through the insurance denials issued by UHC. In principle it might also depend on the sort of non-lethal morbidities or suffering UHC had brought about through its denials policy, but in the interests of simplicity, I’m going to focus in this post exclusively on excess mortality, saving morbidity/suffering for another post. 

Mangione assassinated Thompson on the morning of December 4 of this year, but it’s a mistake to think that the story necessarily begins there. In order to evaluate the moral status of the shooting, we have to put it in a wider context than a one-time interaction on a single day. We have to figure out who initiated force against whom, an inherently retrospective, historical inquiry. 

In saying this, I’m supposing that there’s a moral fact of the matter, not reducible to the claims of American law, about who initiated force on the morning of December 4, and who was responding to the prior initiation of force. That fact is not established simply by knowing that Mangione killed Thompson that morning. Thompson was killed at about 6:30 in the morning. For all we know, Thompson presided over a lethal prior authorization denial at 6 that morning–something he could have done simply by waking up, getting dressed, and functioning as the CEO of UHC. In that case, Thompson was the aggressor, not Mangione. If so, Mangione would not have been guilty of murder.

Notice that the issue of who initiated force is not answered by asking whether Thompson initiated force against Mangione in particular. Mangione was not a UHC policy holder. But Thompson might have initiated force against others who were UHC policy holders, and Mangione might have killed Thompson in the name of those other people. Self-defense is permissible either in one’s own case or in that of others. If wrongful-denials-leading-to-death are wrongful killings, and Thompson was presiding over some, then Mangione’s shooting would have qualified as an attempt to stop them. If Mangione killed Thompson for this reason, the shooting would have qualified as self-defense within the standard legal definition of that concept, as well the ordinary language definition. It may have been quixotic, but it wouldn’t have been murder. 

The only kind of payment that’s never denied in health care

In short, if we want to know who initiated force, it’s a mistake to begin the inquiry by fixating resolutely on the shooting, and proceeding from there. The shooting itself is too late in the sequence to be conclusive. We have to start further back than the shooting itself.(1) 

That said, if we start further back, we have to be clear what we’re looking for. We’re looking for evidence that Brian Thompson is guilty of the wrongful deaths of UHC policyholders through UHC’s denials policy. This is not the same as an inquiry into deaths caused through lack of insurance. I suppose that UHC (and by implication Thompson) can be blamed for excess mortality-through-lack-of-insurance–meaning, excess mortality in the case of people denied care because they were unable to afford UHC insurance–but it seems to me that anyone who wants to make this assertion owes us at least a skeletal account of how liability or responsibility for death works in cases of this sort. Since I myself don’t understand how this argument would go, I’ll ignore it in the rest of this post. 

I should make clear that my aim here is to sketch the beginnings of an inquiry, not to fast-forward to a closing argument. In other words, I myself don’t have the answer to the question I’m posing in this post. So I have no choice but to keep all options open. Wrongful denials leading to death may be wrongful killings, or may not be. Such killings may be happening, or may not be. Such killings may be systematic, or may not be. Mangione’s shooting of Thompson may be justified, or may not be.  I don’t claim to know. Many people want to valorize Mangione, and many want to condemn the valorization. I’m still trying to figure out what happened. 

If you want to figure out whether Thompson was guilty of wrongful killing, you need detailed information on the business strategies Thompson adopted as CEO of UHC. In particular, what strategies did Thompson adopt with respect to maximizing UHC’s bottom line when it came to denials? Did he, for instance, condone or implement an approach to prior authorization denials that wrongfully deprived people of life-saving treatment? Did these deprivations condemn them to death in the name of profits? Was it the denials, in particular, that condemned them to death, or was it something else? Did Thompson know what was happening, or not? If he was ignorant, was his ignorance culpable or not? These are, as it stands, relatively crude questions. Further inquiry would, in principle, refine them, partly by clarifying each item in each question, and partly by raising further relevant issues not mentioned so far. 

Legal or logistical considerations may make it difficult to get all or even most of the information needed to answer these questions. That doesn’t mean it’s impossible, and doesn’t stop us from approximating. As it happens, some health insurance executives have already gone rogue and made some notable revelations about the health insurance industry. Beyond this, there are useful revelations to be found in publicly-accessible reports about the denials process, particularly as regards Medicare Advantage. And there’s an extensive academic literature on denials–some of it in the making–that’s at the very least useful by way of background. 

It’s worth remembering that astonishing revelations have come to light in other walks of life, revealing previously concealed facts that no one could have imagined, often through unauthorized disclosures of information previously regarded as proprietary or confidential.  Think of the Pentagon Papers, the Church Committee hearings, Wikileaks, the Panama Papers, or the Snowden revelations. Closer to health care, there’s a long list of medical scandals which, though initially concealed, were uncovered through long, hard investigation. Something like that could conceivably happen in the health insurance industry. 

Then get prior authorization to fix it

Regardless, we need to keep our eye on the ball.  The fundamental question concerns the relationship between denials policy and wrongful death. To evade this issue is willingly to lose one’s way in the labyrinths of the irrelevant. 

Unfortunately, that’s where most mainstream press coverage has gone. Go out and read maybe a dozen or two of the pieces listed in the Wikipedia entry on Brian Thompson, and ask yourself how much of what’s out there answers (or even poses) the questions I’ve been asking. How much of it tells you whether UHC engaged in wrongful killings in which Brian Thompson played a significant, knowing, voluntary part? If not, what exactly is the point of what you are reading? I’m not denying that there’s valuable, relevant material out there.(2) Nor am I claiming to have done a comprehensive search of everything that’s been said or written. What I’m denying is that most of what’s out there in mainstream coverage is relevant. In fact, huge swatches of it are uninformative. 

Consider one representative case, the three articles published by The New York Times in the immediate wake of Thompson’s death. The first, by Amy Julia Harris and Ernesto Londoño, focuses primarily on Thompson’s personal life. The second, by Reed Abelson, supposedly focuses on his work life.  The third, by Trip Gabriel, summarizes the preceding two.  Together, these three articles assert maybe eight claims. The eight claims in question more or less define the limits of permissible or acceptable inquiry and assertion on this topic in mainstream discussion. 

On the personal front:

1. Thompson was a well-liked person.
2. Thompson had a working class background.

On the professional front:

3. Thompson was, by conventional business standards, a successful businessperson and eventually, a successful executive.
4. Thompson professed a desire to make healthcare more affordable. 
5. Thompson facilitated UHC’s entry into the Medicare Advantage market. 
6. Complaints were made about UHC’s denials policies while Thompson was CEO. 
7. An allegation of fraud was made against UHC this past May, naming Thompson as a defendant. The case has not been decided, and in Thompson’s case, probably cannot be. 
8. The US Department of Justice has sought to block UHC’s attempted acquisition of a number of health care companies on grounds of the alleged antitrust violations involved. 

None of these claims answers the question I posed, or makes any real attempt to. Put another way, the question I’ve posed is distinctly outside of the limits of permissible or acceptable inquiry. 

Claims (1) and (2) are totally irrelevant. Neither (1) nor (2) says anything about Thompson’s work as an executive. 

Losing one’s way in the labyrinths of the irrelevant

Claims (3) and (4) do talk about Thompson’s work as an executive, but not in any useful way. Both are compatible with Thompson’s wrongfully killing people; neither indicates whether he did. As far as our inquiry is concerned, they lead nowhere. 

Claim (5) is merely prefatory to claims (6) and (7). 

Though claim (6) is relevant to the wrongful death issue, it’s vague on the three most crucial questions: Has anyone died from a UHC denial? If so, how? And if so, how was Thompson implicated? Since the issue is never made explicit, it’s overshadowed by side issues. We end up knowing more about the beans that Thompson cultivated when he worked on a farm than about the denials policy he implemented as CEO of UHC. We’re given no sense of whether the complaints about UHC’s denials policies were garden-variety nuisances from complaint-prone policy holders, or anguished matters of life and death where UHC might be guilty in principle of wrongful killing. At face value, then, claim (6) leads nowhere. 

Claims (7) and (8) are indirectly relevant because they bear on UHC’s general tendency to concealment.  I haven’t worked through the details of  the cases involved–they’re still in process–so I won’t try to comment on them except to note their potential relevance, and flag them as something to look into. That said, any relevance they have will be indirect. The cases are not primarily about wrongful killing, so I don’t expect them to give direct evidence of wrongful killing. Then again, I haven’t read them. But like the others, taken at face value, (7) and (8) tell us very little. 

In short, as far as mainstream coverage is concerned, the question I’m pursuing doesn’t exist, and neither do the answers. The inquiry itself is too exotic to figure in mainstream coverage. Yet the relevance of my question should be obvious to anyone. Mangione’s defenders keep acting as though the dashing Luigi killed a remorseless killer. Thompson’s defenders keep insisting that Brian Thompson was just a wholesome midwestern guy cut down in the prime of his life by a cold-blooded punk. The question I’m asking draws attention to ignorance that both sides would like to treat as knowledge. If Brian Thompson was a killer, whom did he kill? And how? On the other hand, if Brian Thompson was just a nice guy from Iowa, what did he spend his time doing as CEO of UHC? If the answer turns out to be deliberately shrouded in mystery (as it is), how can anyone know that what Brian Thompson did with his time was so wholesome? Is it just because he made so much money that we have to believe it? What if overseeing $280B is not by itself proof of virtue?

The mainstream media is incapable of adjudicating the dispute between the two sides. It’s either unwilling or unable to grasp the essential issue that divides them, and so, unwilling or unable to pursue the inquiry that would bridge the divide. But it’s also unwilling or unable to supply an alternative inquiry based on questions of its own. What it hopes to do is throw random facts around in a free associative way so as to split the difference between the two sides. What it ends up doing is pleasing neither side, and keeping us all in the dark.

The one saving grace in the Times’s coverage is a link in the Harris-Londoño article to a 54 page Senate report on health care denials for post-acute care in the Medicare Advantage market (“Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patient Access to Post-Acute Care”). Section 2 of the report, covering pages 21-29, discusses UHC’s denials policies. It makes for interesting reading, and I hope to discuss it here in the near future, but it doesn’t answer (or even bring up) our target question about whether UHC ended up killing anyone as a result of its denials policies. 

There are gestures in the direction of an answer. There are, for instance, suggestive references to “potential threats” to the health of policy holders (p. 4), and an allusion to “significant potential impacts on patient health” (p. 48). There is mention of “inappropriate denials of services,” and of failing to meet patients’ medical needs as a result of denials (p. 49). There’s a suggestion that elders seeking post-acute care are not getting it (p. 51), and that elders in particular are not receiving care to which they’re entitled (p. 52). Vulnerable patients are being forced into “impossible choices” (p. 54), and “harms” are being “done under the current arrangement” (p. 54).

But the focus is narrow. The discussion is about Medicare Advantage, not the health care system as such. Within this context, the focus is on pre-authorization denials for post-acute care, not denials as such. And the authors lament the absence of service-level data, meaning data linking particular procedures with particular denials and clinical outcomes (pp. 47-48). That’s not their fault, but it’s a big omission. If you can’t link procedures to denials, and can’t link those denials to clinical outcomes, you can’t give fine-grained answers to questions about wrongful death through denials. And that’s what we need. 

I hasten to say that service-level data almost certainly exists in the UHC database: I deal with it just about every day. The question is whether UHC is obliged to generate it for public consumption, or even the consumption of the US Senate. UHC neither feels nor (legally speaking) has such an obligation, and it’s worth noting that its Medicare regulators agree: “But despite requests that Medicare Advantage insurers be required to report prior authorization data by service category, CMS [Center for Medicare and Medicaid Services] announced that it will still not require companies to provide service category information…” (p. 48).  Remember this fact that the next time you encounter someone who recites the slogan that “Medicare for All” will resolve all of our health care problems. If that’s true, why isn’t CMS solving this one right now?(3) 

You might think it unfair of me to criticize journalists for not giving us answers to the admittedly difficult question I’m asking, given the paucity of the evidence at our disposal. The Senate Report rightly laments this paucity or opacity, and calls for more transparency (pp. 47-52). But the presupposition of this lament is itself news that almost no one is discussing. The news here is that no one outside of the reporting divisions of insurance companies (and to a lesser degree, denial management companies or hospitals) really knows what’s going on when it comes to denials and mortality. People speak in grand terms nowadays about “the legacy of the Enlightenment,” but on issues like this, we live in the Dark Ages, drowning in data, but adrift in ignorance. It’s the rime of the denial manager: Data, data everywhere, and all our minds did shrink; data, data everywhere, and not a byte to think.

I know a fair number of people who are eager to see the blood of insurance executives run in the streets. My own view is that we should put our guns down, get our spreadsheets out, and brush up on the inferential tools required to make sense of the data. Christopher Hitchens once described Thomas Paine as an “actuarial radical.” If you want a revolution, that’s the kind we need–a nice, bourgeois actuarial one. More data. Better inferences from that data. Fewer bullets. 

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Endnotes

(1) In a widely cited piece, the Johns Hopkins bioethicist Travis N. Rieder wonders out loud how anyone could possibly regard Mangione’s killing Thompson as justified. I’ve explained how: if Thompson presided over an organization engaged in systematic wrongful killing through insurance denials, then shooting him was prima facie an act of self-defense. The difficult question is whether the antecedent is true, not whether the conditional is.

Rieder assumes without much argument that Mangione’s killing of Thompson was murder, then considers the possibility that the killing was justified, only to dismiss it in a sentence: “Shooting an unsuspecting civilian in the back,” he says, “does not resemble any paradigm of justified killing.” A justified killing doesn’t have to resemble any paradigm to be justified; it just has to be justified. If the antecedent of the italicized conditional in the preceding paragraph is true, Mangione’s shooting Thompson was justified. Resemblance to a separate paradigm is unnecessary.

But Rieder’s claim strikes me as false the other way around, as well. In fact, Mangione’s shooting Thompson does resemble a paradigm of justified killing: the justified assassination of an unjust political leader. Almost any assassination of an unjust leader who’s not an active member of the military will involve an attempt at a distance on the life of an unsuspecting civilian. Think of the worst of the Roman emperors from Caligula and Nero on down. Wrong to kill them? Or think of the various assassination attempts on Hitler. Wrong to kill him? It’s absurdly implausible to think that if the target is a civilian, assassinating him must be wrong regardless of what he’s done or the danger he poses.

My own paradigm example is RFK, a civilian whose unsuspecting assassination by Sirhan Sirhan (done with “twenty years’ malice aforethought”) seems to me fully justified on precisely the grounds Sirhan Sirhan actually gave. RFK may have been a “civilian,” but that didn’t stop him from arming the Israeli conquest and occupation of Palestine. From the perspective of a free Palestine, I don’t see what’s wrong with killing such a person, and if the attack on him is going to be successful, the target has to be taken by surprise. My only regret is that Sirhan Sirhan is languishing in prison, not that RFK is dead.

George Wallace’s assassin shot Wallace for fame rather than principle, and did so after Wallace’s supposed moral reformation, but had he done so on moral principle ca. August 1964, it seems to me that the assassination would have been entirely justified. The same might be said of any of the segregationist leaders of the Jim Crow South. In my view, virtually any of them could justifiably have been shot at will. Rieder’s argument not only implies the reverse, but implies that had they been shot, our verdict on the shooting would require us to fixate on the shooting itself while bracketing anything that happened before it. That strikes me as a reductio.

(2) Particularly suggestive for what they say (however inconclusively) about the connection between denials and mortality:

• Eleisha Flanagan et al, “Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval,” The American Surgeon (Feb. 2016)
• American Medical Association, “Survey: Patient Clinical Outcomes Shortchanged by Prior Authorization,” (March 19, 2018).
• Society of Actuaries, “Emerging Underwriting Methodologies and their Impact on Mortality Experience Delphi Study,” (August 2018)
• William E. Bennett, “Insurance Denials of Care Amount to Unlicensed Medical Practice,” Journal of Managed Care & Specialty Pharmacy (July 2020)
• J. Lee, et al, “Beyond Being Insured: Insurance Coverage Denial as a Major Barrier to Accessing Care During Pregnancy and Postpartum,” Clinical Nursing Research (June 2023)
• Commonwealth Fund, “Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer,” (Oct. 26, 2023)
• Alex Stockton, “Denying Your Health Care Is Big Business in America,” The New York Times (March 14, 2024)
• Helen Ouyang, “What Doctors Like Me Know about Americans’ Health Care Anger,” The New York Times (Dec. 8, 2024)
• NPR interview with Miranda Yaver (Dec. 11, 2024)
• STAT, “Inside STAT’s Investigation of UnitedHealthCare,” (Dec. 23, 2024).

Also valuable in a more general way is Eric Bricker’s AHealthCareZ website (thanks to Debbie Peikes for the latter reference).

(3) Answer: because the problems with the US health care system are too path-dependent to be resolved by any one fix, and because any specifically political fix tends to be confounded by problems specific to the peculiarities of the US political system. For a clear statement of the issue, see Tsung Mei-Chang’s Epilogue to Uwe Reinhardt’s Priced Out: The Economic and Ethical Costs of American Health Care. 

In a previous post, I asked rhetorically why it strikes Mangione’s admirers as so obvious that health insurance denials that lead to premature mortality justify assassinations but that other kinds of denials with similar results seem not to, e.g., denials of disability benefits.  It turns out that this is not an idle speculation: there is a connection between disability-benefit denials and mortality. See Bernard Black et al, “The Effect of Disability Insurance Receipt on Mortality,” Journal of Public Economics (Jan. 2024). If death-causing health insurance denials can justify the assassination of CEOs, shouldn’t death-causing disability denials justify the assassination of administrative law judges? I offer this not as a suggestion that people start shooting administrative law judges but as an inducement to strive for greater coherence on the issue of assassination.

I write here in my own name, on my own responsibility. I am not a spokesperson for my employer or any other organization.