The manifesto, discovered at Luigi Mangione, spends less time discussing the quality of health care in America before being charged with killing UnitedHealthcare CEO Brian Thompson. It doesn't mention any particular health issues that Mangione complained about Reddit or any complaints he may have been receiving treatment. Instead, the majority of the notes talk about the size of UnitedHealth Group, the parent company of UnitedHealthCare.
United states, “It's one of the largest companies in America by market capitalization, only behind Apple, Google and Walmart.” The company says it is “simply becoming too powerful and continues to abuse our country because the American people have allowed them to escape it.” In other words, Mangion seemed not to be angry at healthcare in itself, but he was angry at monopoly. A backpack found in Central Park, where police believe they belong to Mangion, was packed with exclusive money. (Mangion pleaded not guilty to the shooting.)
The manifesto makes some facts wrong, but United Health actually ranked 14th in market capitalization at the time of the shooting – that refers to a very realistic trend. A major American business sector. Whether you buy office supplies, book vacations, or search the internet, we are often the mercy of a few companies that control a particular corner of the economy. Despite a century of antitrust laws and litigation, American businesses are bigger than ever.
This is especially true when it comes to healthcare. The government's accountability agency has found that only three companies control at least 80% of the health insurance market in most states. UnitedHealth in particular has been buying companies from across the health sector over the past few years, turning it into a vertical integration giant that manages health insurance, health services, medicines and medical data. Last year, the Justice Department launched an anti-trust investigation of the company, urging UnitedHealth to remove two proposed acquisitions. DOJ also sued to block the acquisition of UnitedHealth of Home Healthcare's rival provider Amedisys. This is what UnitedHealth calls “a fierce defense” overreach.
Of course, businesses integrate for all sorts of reasons. One, using size allows you to take advantage of economies of scale. A report from accounting giant PWC found that large hospitals have lower per patient costs. Insurance companies also save money by serving a large customer base. The more people you cover, the lower the risk (and cost) for each person. In a statement, UnitedHealth said: “The $5 trillion US health system is deeply fragmented into a service fee model that brings optimal patient outcomes, increased mortality, reduced patient experiences, redundant care, and waste, and is now a rooted service model. It's rooted. A lifelong course.”
We have joined a new era in which monopoly companies “higher prices and tighten quality, service and wages.” Marshall Steinbaum, economist at the University of Utah
However, monopolies are sudden costs. If the market is managed by a small number of companies, if the economists discover, the company can raise customers and provide outdoor products and services simply because consumers don't have meaningful options . Farmers who buy John Deere tractors, which manage the majority of the tractor market, are not permitted to modify their own equipment as they require farmers to use repair services. (This practice has been challenged by class actions and lawsuits by the Federal Trade Commission.) Similarly, Apple customers are unable to repair their phones and are not revising their current model. They are not looking to buy new products. Also, a 2015 study by Yale Economist Zach Cooper found that patients in hospitals that are not competed were about $1,900 more expensive than hospitals with four or more competitors.
In recent years, we have joined a new era in which monopoly companies “higher prices and tighten quality, service and wages.”
Americans know the problem well. In a June Gallup poll of American adults, 41% of respondents said they had “very little” trust in “big business,” making it the third largest in the US after only TV news and Congress. It has become a trusted institution. A survey conducted in the past spring found that four of five respondents in rural Swing State agreed that “corporate monopolies run our entire economy.” Also, in a recent poll of registered voters, 41% of respondents under the age of 30 say the killing of the CEO of United Healthcare is “acceptable” or “somewhat acceptable.”
That may be shocking, but we've been here before. At the end of the 19th century, Americans were transformed into violence as major trust integrated the entire industry. In 1877, workers rose to a massive general strike in which 100 people died, in response to the railroad cut wages. In 1894, a railroad strike against Pullman was extremely heated, causing a pitching battle with the Illinois National Guard, killing dozens of strikers. In 1920, a wagon filled with explosives parked on Wall Street, targeting banker JP Morgan. The bombing killed more than 30 people and injured hundreds more.
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The question is, why did anti-corporate violence subside? What happened to contain the open up rebellion – and why is it that so many Americans seem willing to embrace violence as a response to monopoly?
Violence against monopoly dissipated for two reasons. The first was government regulations. The second was the lowest price.
After the stock market crash in 1929, the government began cracking down on large corporations and dissolved its monopolies on oil, tobacco and railways. At the same time, the New Deal allowed unions to fight businesses on a more equal footing, with unions winning higher wages and better health insurance. Taken together, these efforts helped create a large, prosperous middle class. For decades, things seemed to be going well for ordinary Americans.
Then, in the 1980s, the government shifted its philosophy to antitrust enforcement. Rather than treating integration as an inherent evil, we adopted what has become known as the “consumer welfare” standard. If companies kept prices low, if their thinking went ahead, it didn't matter whether the market was cornered by a few companies. There is no economic harm or legal foul.
A new philosophy has allowed integration to soar without causing consumer anxiety.
As Walmart and Amazon began to take control of the economy and began to close small stores, Americans accepted local businesses and low wage losses in return for their abundant cheap and convenient goods and services. Amazon may rule the world, but who cares? The prices were low, the delivery was fast, and the revenue was free.
But now, as prices rise and businesses begin to take advantage of market control, more and more Americans are realizing that if businesses grow too big, normal people pay the price. And when the system feels unfair, the courtesy itself begins to crumble – especially when the citizens feel meaningless and unreliable. As history has repeatedly shown, helplessness breeds violence.
Amazon may rule the world, but who cares? The prices were low, the delivery was fast, and the revenue was free.
In fact, keeping things citizens was the obvious reason the government decided to suppress monopoly in the first place. Speaking on the Senator's floor in 1890, Senator John Sherman urged fellow lawmakers, many of whom were seen by the Railway Barons, to support the laws that underlie the anti-monopoly movement. Congress had to choose, Sherman said: beware of the public's call to disband the monopoly or “prepared for socialists, communists and nihilists.” Today, with deep erosion of trust in large corporations and public satisfaction with the health system at its lowest level in 24 years, we may find America at a similar crossroads.
Robin Kaiser-Schatzlein is a freelance journalist who writes for the New York Times, The New Republic and many other publications. He writes a book about authoritarianism in the American workplace, published in early 2026.
