A Learning a Day

I recently started building products focused on healthcare affordability in the US. As I was ramping up on a new space, the biggest question that sparked my curiosity was: how did we get here? This question is the inspiration for this weekly series chronicling the decisions, accidents, and breakthroughs that built the US healthcare system.

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In 1933, a 27-year-old doctor named Sidney Garfield borrowed money from his father, drove out to the Mojave Desert, and built a 12-bed hospital in the sand.

He had signed a contract to provide medical care for 5,000 construction workers building the Colorado River Aqueduct — the most ambitious water project in California’s history. The nearest hospital was hours away. The work was dangerous and the desert heat was unforgiving.

Garfield’s radical belief was that a doctor’s job was to keep people healthy, not just treat them when they broke down. So, he introduced safety education, hydration protocols, annual checkups. Injury rates among his workers dropped from 27 per 100 in 1934 to 3 per 100 by 1937.

The medicine was working. But the business was not.

Insurance companies paid slowly, or didn’t pay at all. Garfield kept treating workers regardless — you couldn’t turn someone away in the middle of the desert. But the hospital was quietly going broke. He was weeks from shutting the whole thing down when an insurance executive named Harold Hatch came to see him with an idea.

Hatch proposed flipping the payment model entirely. Instead of billing after treatment, the insurance company would prepay Garfield a fixed amount per worker per day in exchange for a guarantee of care. The rate: a nickel a day per worker for work-related injuries.

The revenue stabilized immediately. With predictable income, Garfield could plan ahead, hire properly, and invest heavily in prevention. And prevention was now in his direct financial interest. A healthy worker cost him nothing. A sick one cost him everything. For the first time, a doctor’s incentives were perfectly aligned with his patients’ wellbeing.

Garfield extended the offer directly to the workers: pay an extra nickel a day from your own pocket and I’ll cover everything — work injuries, illness, your whole family. About 95% of workers signed up. The hospital thrived. And Garfield quietly proved something that would take American healthcare decades to fully absorb: keeping people well was better medicine, and better economics, than waiting for them to get sick.

When the aqueduct project ended in 1938, Garfield was preparing to go into private practice when a colleague mentioned his work to a man named Henry Kaiser — the builder behind the Hoover Dam, the Grand Coulee Dam, and soon the Liberty ships that would help supply the Allied war effort. Kaiser’s Grand Coulee workers had almost no access to medical care. He invited Garfield to come north.

When Kaiser visited Garfield’s hospital, the two men spent the whole day together talking. At the end of it Kaiser told him: “If your plan achieves even half of what you claim, it should be available to every person in this country.”

Kaiser was a builder who thought in scale. In Garfield’s prepaid model he saw something that could work far beyond a desert construction site. He was right — but neither of them could have imagined just how far it would go.

Next week: Kaiser takes Garfield’s idea to his WWII shipyards and scales it to 200,000 workers. It is a fascinating story of how a wartime health plan became the largest nonprofit health system in America.

A friend, after significant career success, found herself in rooms with some incredibly rich and successful people. She shared that the biggest learning she took away was that people are the same.

Many insecure. Many jealous. Some smart. Some thoughtful.

Their wealth and success didn’t make her any more likely to like them.

We project a lot onto success — wisdom, contentment, confidence.

But it is worth reminding ourselves that those are exactly that -> our projections.

The intent we ascribe to a person is the lens through which we view their actions.

The same behavior — a blunt comment, a last-minute change, a moment of silence — reads completely differently depending on whether we think the person means well or not.

It takes real effort to judge an action objectively. The default is to see it through the lens of the person we’ve already decided they are.

At any given moment, we can either spend time finding excuses to change or wait for the next convenient milestone to start the work.

One of these increases our odds of success by at least 10x.

There’s a great story from the late Prof Clay Christensen that I think about from time to time.

Andy Grove, CEO of Intel, requested Prof Clay Christensen to visit Intel headquarters and explain his theory of disruptive innovation. When Clay arrived, Andy said he could only spare 10 minutes and asked Clay to explain what it means for Intel.

Clay instead showed Andy a diagram of his theory and began walking him through it.

Ten minutes in, Andy interrupted impatiently – “Look, I’ve got your model. Just tell us what it means for Intel.”

“Andy, I can’t.” Clay persisted and went on to share the story of the disruption of the steel mill industry.

When he finished the story, Andy said, “I got it.” and explained how it applied to Intel.

Prof Christensen shared the story from time to time to drive home the idea that Andy knew more than he would ever know about his business. Instead of telling him what to think, his role was to teach him how to think.

It is a fantastic example of what great coaching looks like. And it is one I do my best to remember every time I’m attempting to coach myself.

When a good friend and I were talking about the NBA recently, he turned the conversation toward the Oklahoma City Thunder — who won the championship last year — and urged me to take a deeper look at what their executive team was building. It felt, he said, like something special.

I’d been loosely following the playoffs, and the Thunder’s dominance has been hard to ignore. When ESPN published a long piece about them, I was intrigued. Four reflections:

(1) Environment as competitive advantage. GM Sam Presti has engineered chaos out of existence — perfectly aligned basketballs, identically folded towels, a lawn outside that looks trimmed blade by blade. The obsession with order isn’t aesthetic. It’s a philosophy: control what you can control, and let success be the natural byproduct.

(2) No one wants the credit. SGA or Shai Gilgeous-Alexander, the reigning NBA MVP, credits the staff. Presti hides from compliments. Coach Daigneault’s nightmare is someone crediting him. In a league where ego is the default currency, the Thunder have somehow built a team where everyone is sprinting away from credit.

(3) Presti drafts humans, not players. When he visited Gonzaga to scout Chet Holmgren, the basketball evaluation was already done. He was there to watch him be a person — how he moved through a room, how he treated teammates. As Coach Daigneault puts it, he’s method acting, imagining the player walking around their building.

(4) Depth as a system, not an accident. When Jalen Williams is out injured, Ajay Mitchell steps in and averages 22.5 points against the Lakers. Mitchell’s minutes go to Jared McCain, who drops 18 points in 18 minutes. It doesn’t feel like improvisation — it feels designed. As Daigneault says, there’s a constraint on minutes and roster spots, but no constraint on the investment made in every single player every single day.

All of this means the Thunder have insane strength in depth, remarkable camaraderie, and the foundations of a sporting dynasty to likely rival the greatest.

It was an inspiring read.

A friend who is a lifelong New York Knicks fan has been eagerly following the New York Knicks these playoffs. Watching them sweep the 76ers and cruise back into the Eastern Conference Finals got me thinking.

Last year, the Knicks also made the Eastern Conference Finals — their deepest run in years. They lost to the Indiana Pacers. Then they fired their coach.

Their coach, Tom Thibodeau, had gotten them further than they’d been in a long time. Why change it?

But the pattern keeps showing up. The Chicago Bulls fired Doug Collins in 1989 after he’d taken them to the Eastern Conference Finals for the first time in 15 years. They replaced him with his own assistant, Phil Jackson. Phil Jackson instituted the “triangle offense”, a significant departure from the way they played. Six championships followed.

Similarly, the Golden State Warriors fired Mark Jackson in 2014 after back-to-back playoff appearances for the first time in decades. They hired Steve Kerr, who had never coached before and upset their players. Four titles followed.

In each case, the previous coach had done something real and hard. They’d built the culture, changed the trajectory, earned genuine loyalty. That’s what made the decision so difficult. And that’s also exactly why it had to be made — because what got them there wasn’t going to take them further.

The Knicks will likely not win it this year — both western conference finalists look formidable. But the decision to change already looks like the right one.

This shows up in companies and individual careers too. The skills and habits that create early success can quietly become the ceiling. Recognizing that — and doing something about it — takes a different kind of courage than just grinding harder.

What got you here won’t get you there.

“No one tells you running is 10 percent cardio and 90 percent negotiating with the voice begging you to quit.” | David Dack

Beautifully put.

And applicable to nearly every hard thing we attempt in our lives.

I recently started building products focused on healthcare affordability in the US. As I was ramping up on a new space, the biggest question that sparked my curiosity was: how did we get here? I plan to write about this weekly with the goal of chronicling the decisions, accidents, and breakthroughs that built the US healthcare system.

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In 1940, only 9% of Americans had health insurance. A decade later, it was nearly 50%. By 1960, almost 70%.

What changed? A wartime wage freeze.

In 1942, FDR signed the Stabilization Act — freezing salaries to combat wartime inflation. With millions of men at war, labor was scarce and wages were surging. The freeze was a blunt fix for an urgent problem.

But benefits were exempt. So employers competing for workers did the logical thing — they competed on health coverage instead. Henry Kaiser, owner of a construction company who was branching out into shipyards, was among the first to figure out how to cover his workers comprehensively, keeping his shipyard workforce healthier and more productive. Others followed fast.

Then in 1954, the IRS codified a tax exemption making employer health contributions tax-free for both employer and employee. A $500 health plan was now worth more than a $500 raise. The economics became self-reinforcing.

For millions of Americans, this was transformative. A factory worker in Ohio who had never seen a doctor in her adult life suddenly had coverage. She went in for a check-up. They found something early. She lived another 40 years. That story played out across millions of households.

In 1944, when jobs lasted a lifetime, few thought to ask the obvious question: what happens when you leave?

The answer took decades to arrive — and it shaped everything that came after.

Next week: Henry Kaiser’s health plan for his shipyard workers became something far larger. You almost certainly know his last name.

In the Netflix documentary “Court of Gold,” Steve Kerr — who won three championships as a player with the Chicago Bulls and four more as coach of the Golden State Warriors — shares a fascinating reflection on what winning cultures have in common.

A sheer intensity that comes from competitiveness and playing to win.

A sense of joy and fun while doing so.

And a genuine happiness when others on the team succeed — a collective delight in watching every person around you flourish.

It’s a lovely articulation. And when I reflect on my favorite team experiences, I find all three were present too.