They’re wrong.

It broke on a specific day, in a specific year, when a decision was made that redirected the entire system away from what was working and toward something that has never worked since.

The year was 1973. The decision was the HMO Act.

Before that moment, American healthcare — whatever its flaws — operated on a relatively straightforward principle: you got sick, you saw a doctor, and patients paid the bill. Costs were rising, yes. But the incentives were reasonably aligned. Physicians practiced medicine. Employers bought coverage. Insurers managed risk.

The HMO Act changed the underlying logic of the entire system. It didn’t just introduce a new payment model. It handed the keys to a set of intermediaries whose financial interests were structurally opposed to the interests of patients and employers alike.

I was not yet thirty years old in 1973, just beginning a career that would put me on the employer’s side of the table for the next five decades. I watched what followed in real time — the managed care revolution, the Clinton reform push, the Affordable Care Act — each one promising to fix what the last one broke.

None of them touched the original wrong turn.

That’s what this newsletter is going to be about. Not politics. Not ideology. The mechanics of how we got here — and what a market-based path out actually looks like.

Next week: what managed competition was supposed to do, and why it failed the moment it left the classroom.

— Robert Christadore

I'd like to hear from you. Where were you in 1973 — and when did you first realize the healthcare system wasn't working for you? Leave a comment below or reply to this email. Every response gets read.