Grading the World's Shortest Manifesto

It gets an F and the student has earned the death penalty

It’s time to grade the short manifesto written by the suspected killer of UnitedHealthcare CEO Brian Thompson. Let’s go line-by-line. It starts:

To the Feds, I'll keep this short, because I do respect what you do for our country. To save you a lengthy investigation, I state plainly that I wasn't working with anyone. This was fairly trivial: some elementary social engineering, basic CAD, a lot of patience. The spiral notebook, if present, has some straggling notes and To Do lists that illuminate the gist of it. My tech is pretty locked down because I work in engineering so probably not much info there. I do apologize for any strife or trauma but it had to be done.

The killer fesses up to his crimes. That’s a good start, but it hardly makes a manifesto.

Frankly, these parasites simply had it coming.

By this, he’s presumably referring to Brian Thompson, health insurers more generally, and perhaps medical providers, or even regulators—who knows! So presumably the next few lines should tell us why “these parasites” had it coming. Let’s see:

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

This is not off to a good start. The first fact—that the U.S. has the “most expensive”—healthcare system is poorly conceived. For one, “most expensive” shouldn’t be what the killer wanted to say. That could mean the prices in the system, or the total costs of the system, or the cost per effective unit of care, or a lot else. What he wanted to say was that the U.S. spends the most on healthcare and it doesn’t get a lot for it. But that’s wrong.

Firstly, the U.S. does not spend all that anomalously much on healthcare. It is just vastly wealthier than its peer countries:

Others have explored this in greater depth, but the gist of it is that Americans are richer than everyone else and healthcare is a superior good, etc. etc., so they simply consume a lot more healthcare—and I mean “more” very literally, because Americans do not just suffer from higher prices. For example, you can predict America’s high health spending from the amount of surgeries it does:¹

Source

With that out of the way, secondly, America’s poor life expectancy has little to do with its healthcare system, and what amount it does have to with the healthcare system likely favors America. Compared to other rich countries, Americans do live shorter lifespans, but about 90% of the gap for men and two-thirds of the gap for women is explained by a handful of well-known observables:

Source. Note: This shows the portion of each country’s lifespan gap with the U.S. that’s statistically attributable to different factors.

America lags behind its peer countries largely due to obesity and its comorbidities, violence, drug and alcohol abuse, and needless risk-taking. But notice: it generally leads in screenable and treatable cancers. This makes sense because the U.S. screens far more than its peers, and it screens far more aggressively. For example, the U.S. recommends routine colonoscopies past age 45. These may or may not be effective in their own right, but they are emblematic of America’s broader support for intensive screening, some of which definitely works.

Others have noted that Americans lag for the same sets of reasons: obesity, eating too much, being too lazy, being violent, driving fast cars and, more unfortunately, being near people who drive fast cars, and so on. It should also be noted that much of the obesity-related death delta against the U.S. doesn’t seem unique to the U.S. It appears more like a disease of affluence.

The 2024 John’s Hopkins Life Expectancy Report reiterated these facts. It reported that 57% of the life expectancy gap between the U.S. and the U.K. was down to cardiovascular disease, another 32% was down to drug overdoses, 20% was down to firearm-related homicides and suicides, and 17% was due to motor vehicle accidents. But, as the above treatable/screenable cancer note suggested, the report also concluded that, if anything, America is ahead when it comes to mortality from conditions the healthcare system can actually affect—namely, COVID and cancer.²

The killer’s attempt to smear America’s healthcare system doesn’t really hold up. He could have just said America is rich and Americans are fat and violent, but he wanted to blame health insurers, or the health establishment, or someone in healthcare, even though healthcare is effectively totally irrelevant to this line of concern and, if anything, looking like a mark in favor of America’s system.

Ironically, the killer contributed to America’s poor life expectancy in a predictable way: by killing a middle-aged man with a firearm.

United is the [indecipherable] largest company in the US by market cap, behind only Apple, Google, Walmart.

This is just wrong, and I think he might have gotten this from a book that was not just outdated, but wrong too. At the moment of writing, Apple is on top, followed by Nvidia, then Microsoft, then Amazon, then Google, then Facebook, then Tesla, then Berkshire Hathaway, then Broadcom, then Walmart, then Eli Lilly, then JPMorgan Chase, then Visa, then, finally, UnitedHealth. [Edit: A commenter pointed out that the killer probably meant revenue rather than market cap. As it turns out, the order the killer listed the companies in was repeated on Wikipedia, just swap Amazon for Google. Mystery maybe solved, and possibly an even more of an indictment of the killer’s reasoning.]

But even if this were right, who cares? That United is large doesn’t say anything about it being run poorly, or failing to keep people healthy, or anything else. Even being profitable or paying its executives well wouldn’t tell us much about how much care United provides. As

Noah Smith

recently wrote: “if UnitedHealth Group decided to donate every single dollar of its profit to buying Americans more health care, it would only be able to pay for about 9.3% more health care than it’s already paying for. If it donated all of its executives’ salaries to the effort, it would not be much more than that.”

[United] has grown and grown, but as [for] 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 allowed them to get away with it.

Since health insurers have capped profits and their profits could only ever make a minimal difference to the amount of care they provide without some sort of major change in prices, this is just facially wrong and it is an obvious, massive overstatement.

Reading this, you have to wonder: What exactly is insurance’s role supposed to be in the killer’s mind? Most insurers aren’t even close to taking the maximum amount of money they can given medical loss ratio regulations or the availability of upcoding in Advantage plans or so much else, and if they were, the amount of care being provided to Americans wouldn’t be all that different. But, if they were denying requests for care at much higher rates, perhaps prices would be lower and out-of-pocket spending would be easier. It seems unlikely that’s worth it, but on some margin, it would benefit someone.

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.

This is an admission that the killer was ignorant and that this whole screed is self-rationalizing evil. Why would you ever think you’re qualified to literally kill someone over your beliefs that you’re admitting you’re not the most qualified person to explain? What are these beliefs anyway? So far, the only concrete views have been ignorant—no rational motivation has been supplied, and the note’s about to end!

But many have illuminated the corruption and greed (e.g.: Rosenthal, Moore), decades ago and the problems simply remain.

Apparently these are the people who’ve exposed the system and lain the killer’s motive bare for us all to understand. Apparently at least one major issue with the healthcare system is “corruption and greed” and way-too-generically-named authors³ are going to explain that. But the problem is not corruption and greed, not in healthcare, nor in almost any other domain. If you ever find yourself thinking “Aha, the issue with [this huge domain] is corruption and greed!” then you’ve just admitted to yourself that you’re done trying to understand real, substantive issues, and you’re happy to start pointing fingers instead.

Given what I’ve already said, it should be apparent enough that “corruption and greed” aren’t fitting explanations for the things the killer was upset about. But they’re also not really fitting explanations for much else either. Take a bad law, like the Affordable Care Act’s ban on new physician-owned hospitals. It was definitely a bad regulation. What was it motivated by? Not corruption and greed, but by a genuine concern that physician-owned hospitals worked poorly. When the studies came out years later and they showed they were actually better than other hospitals, it was too late.

Some people have tried to create a story about how corruption and greed led to the ban on new physician-owned hospitals, but they’re ignoring that the motivations of the lawmakers and regulators clearly weren’t corruption and greed. They were vocally concerned about performance, and maybe some people promoted those concerns in their own interest, but the dominant influence that led to the ban was good people thinking it would help the American people.⁴

Lots of healthcare is like this: genuinely good people do genuinely bad things, not because they’re bad, but because they just don’t know any better. And people can exploit the rules good people make, but that doesn’t really make them bad either. I could ramble about this, but I won’t, because there’s something more pressing about this section of the manifesto: it’s just lazy! This is your manifesto, it’s your time to write volumes and go wild, not to hold back. Tell us what’s on your mind—we all want to read it!

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

This is an empty comment.

Evidently I am the first to face it with such brutal honesty.

Killing someone for what seems to be no good reason is not a signal of honesty, it’s merely inhuman.

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I give this short manifesto a failing grade. It did not provide even one iota of support for its writer’s actions and basic fact-checking apparently wasn’t involved in making the case for premeditated murder. If the killer was—as many have now alleged—frustrated over back pain, that’s unfortunate, but that can never be an excuse. And if back surgery still isn’t in the cards for the killer, I think everyone can now agree he should be on antipsychotics, at least until he receives a well-earned execution.⁵

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Postscript

It now seems to be the case that the killer had back surgery that went fine, and he wasn’t enrolled in a United plan. Given this information, my theory for why he killed Brian Thompson is that he was angry at healthcare in general and he wanted to go after the CEO of the biggest healthcare company he could find. As to why he killed someone in cold blood, I think that might have more to do with psychosis, but that’s admittedly much less clear. Someone DM’d me to suggest the answer might’ve been mania. They suggested that the manifesto was too coherent to be written by someone suffering from schizophrenia.

1. Two things:

1. The amount of surgeries aligns with how much care is provided across the rest of the healthcare system.

2. The U.S. is sometimes an outlier in these sorts of comparisons, but that’s not very directionally consistent. Check out RandomCriticalAnalysis’ long post on this for examples.

2. Do note that it might be the case that America’s cancer death rates could be superior because Americans die of cardiovascular disease or the other causes I’ve discussed prior to being able to be diagnosed with or to die of (identified) cancer. But since the delta to explain is actually only a scant few years, this seems unlikely.

3. I think they’re Elisabeth Rosenthal and Michael Moore, but the names are so generic that I could be wrong. Either way, they didn’t ever write or produce anything that supports the killer’s actions.

4. Certificate of Need laws have an even less suspect moral origin and an even more serious negative impact.

5. I am aware it’s very unlikely given the state the murder took place in.