When Dr. Nicholas Rosenlicht, a psychiatrist and author with a Berkeley practice, heard about the shooting of United Healthcare CEO Brian Thompson on a Manhattan street on Dec. 4, he was surprised and saddened by the act.

But even before bullet casings were found with the words “delay” and “deny,” tactics insurers use to avoid paying claims, and before Luigi Mangioni was arrested Monday with a handwritten manifesto condemning the health care industry for putting profits above patients’ lives, Rosenlicht could see why a large swath of the public immediately embraced Thompson’s killer as a folk hero.

“People are really frustrated,” Rosenlicht said. “We’re all becoming dehumanized by our health care system and feeling powerless, so much so that the shooter is viewed as a kind of Robin Hood. We can all understand his motives even if we don’t support murder.”

Rosenlicht, a clinical professor at UC San Francisco School of Medicine who has spent 40 years in psychiatry and has a practice on Solano Avenue, is himself frustrated by the American health care system.

His first book, My Brother’s Keeper, came out Oct. 1 with the subtitle “The Untold Stories Behind the Business of Mental Health — and How to Stop the Abandonment of the Mentally Ill.” The book focuses on mental health and offers a scathing critique of the health care system in general, following its evolution as a “model for the world” in the middle of the last century to a “bloated embarrassment” in “the only developed country where health care is a business and not a function of our government.”

In 1953, the government subsidized employers’ health insurance, which was managed by private companies, by making them tax free, and some insurers, like Blue Cross, were originally nonprofit. But some for-profit companies realized they could “kick out people who weren’t profitable and go after rich people,” Rosenlicht said. As health care costs rose, topping 7% of GDP by the early 1970s, so did national concern. The Health Maintenance Organization Act of 1973, which applied free-market theories about competition and efficiency to health care, was intended to lower costs but actually ended up having the opposite effect, Rosenlicht said.

“It was well intended,” he said. “The idea was to bring in business models to rein in costs. Instead it turned health care into a business venture rather than as a benefit for society.”

Health care now makes up 20% of GDP.

The result, Rosenlicht said, is that the U.S. consistently comes in last place in terms of health outcomes, though we pay more than twice of what other developed countries pay, citing statistics from the independent research group the Commonwealth Fund, which has been analyzing health care systems around the globe since 2004. Its Sept. 19, 2024, report compared systems across 10 countries, including the U.S., Australia, Canada, Germany, the United Kingdom and Sweden, found that the U.S. had lower life expectancy and higher rates of death and disease despite spending the most on health care.

In the book, Rosenlicht cites United Healthcare, the nation’s largest health insurance company, serving some 50 million people, as the poster child of a bigger-is-better approach that encourages consolation and monopolization to maximize both market share and profits.

According to Forbes, United Healthcare has the most expensive premiums in the nation and denies more claims than other insurers, at a rate nearly double the industry average. The company was recently slammed by a Senate report for denying nursing care to patients recovering from falls and strokes on its Medicare Advantage plans and faces a class action lawsuit for using AI algorithms to automatically refuse payment.

Rosenlicht also cites the tremendous growth of the health care industry, which is now the largest and most profitable sector for private equity and venture capital investment. United Healthcare’s profits have grown from $15 billion in 2009 to $32.4 billion in 2023, which Rosenlicht considers “obscene,” along with Thompson’s more than $10 million salary.

Still, Rosenlicht doesn’t believe in placing the blame for an exploitative industry solely on one executive’s shoulders. “Does he deserve to be murdered? No,” Rosenlicht said. “He was just being an effective CEO of a health care corporation. The problem is the system has the wrong incentives.”

The business model that has been created is to deny as many people as possible and to bill people as much as possible, Rosenlicht said. “They make money by overcharging through their Medicare Advantage program and by overcharging taxpayers for services that can be done cheaper or are not needed.”

Rosenlicht cited a 2022 Gallup poll that found that more than a third of Americans reported that they or a family member have put off medical treatment because of cost, including more than one in four who have a serious condition. That number jumps to 83% for the uninsured.

As for Mangione, Thompson’s suspected killer, Rosenlicht characterized his behavior as consistent with someone in need of mental health care.

While some of Mangione’s defenders see his actions as a form of violent radicalism that ultimately creates change, Rosenlicht believes that Mangione’s mental health struggles turned him from a high-achieving high school valedictorian, star athlete and gamer into someone who committed what is basically a self-harming act.

Rosenlicht saw parallels between the Thompson shooting and the acquittal of Daniel Penny in the chokehold death of Jordan Neely, a homeless man with a history of mental illness, both incidents that have taken place in New York within a few days of one another. He sees them as two representations of a failing health care system.

On the one hand, Mangione’s inability to get the help he needed led to an act that garnered sympathy from the public, while Penny did not even view Neely “as a human being,” Rosenlicht said, and a New York jury agreed, refusing to convict Penny of homicide or manslaughter. “People who are ranting and raving and scary — they’re abhorrent to us.”

In the book, Rosenlicht shows how people with mental illness not getting the treatment they need has contributed to homelessness and the prison system.

Rosenlicht has struggled with a broken and “bloated” health care system within his own specialty and practice, where patients who need psychiatric help sometimes cannot afford it. To see a psychiatrist, patients are going to pay out of pocket 15 times more often than primary care, he said, for a variety of reasons.

Psychiatrists often don’t want to haggle with insurance companies over pricing and patients often seek to avoid the stigma of having mental health services appear on their medical records. Though he accepts Medicare and offers a sliding scale for patients, Rosenlicht himself does not deal with private insurance companies. He would rather spend his time with patients than “wrestling with an insurance company,” he said.

In addition, for-profit insurance companies also don’t treat mental illness on par with physical ailments. “There shouldn’t be differences if it’s your brain or your liver,” he said.

To improve health care, Rosenlicht supports a single-payer system like Medicare — which is favored over private insurance by Americans who are on it — and moving health care back into the government and public health realm.

“It is time to make health care a right and to have the government provide basic care for human beings,” he said.