The space between the care that providers want to give and the care that the patient receives is enormous. The area is full of barriers — tasks, paperwork, and bureaucracy. Each is a point where someone can say no. There are endless appointments with different doctors, tests that need to be scheduled, and a wait for treatment that could extend weeks or months.

Until 1973, federal law did not encourage health insurance providers from functioning under a profit motive. By the late 1990s, 80 percent of MCOs were for-profit organizations, and only 68 percent or less of insurance premiums went toward medical care. The remainder was paid for MCO executives’ and salespersons’ salaries. In retrospect, it was a huge mistake.