Over the past fifty years, our health care system has steadily shifted into the model we see today, where private corporations receive public dollars to make a profit off of patients. This model is largely due to the long career of one bureaucrat turned private equity tycoon you may not have heard of: Tom Scully, the man behind Medicare Advantage, physician payment plans, Medicare Part D, and more.

I’ve watched and listened to virtually every scrap of tape of Scully over the last 35 years, and I conducted a long interview with him in June. I think his beliefs are sincere. He thinks government price-setting doesn’t work, and that empowering private insurers that put their own money at risk leads to better and more efficient care. He believes poor people should be covered generously, but all other patients exposed to cost to reduce overutilization. And he wants the best hospitals and nursing homes and clinics to be paid more than the worst, to force advances in quality.

His ideology has created the predicament we are currently in, where we spend more per patient than any country in the world despite shocking inequities in accessibility of care. He has created a lifetime position for himself as one of the few people who can navigate and exploit the maddeningly complex jumble. Our health care system has become a bonanza for private corporations looking to profit from public money, as long as they hire armies of specialists to navigate miles of red tape—people like Tom Scully. The public isn’t so lucky.

You can read the entire story on the website today.

This story is part of our ongoing series on the business of health care—the inner workings of the monopolies and cartels extracting ever-greater sums for ever-lousier outcomes, and the policies and protocols pushing doctors and nurses to the brink—and increasingly into labor unions. You can read our entire series on the business of health care as it is released here.