Health Insurance

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HEALTH INSURANCE

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The social and economic vulnerability of wage laborers gave rise to nineteenth-century reforms that are the forerunners of modern health insurance. When the flow of resources to a household depends on wage labor, sickness for any prolonged period threatens the family's ability to secure food and shelter. The practice of organizing workers to contribute a portion of their wages to health (or sickness) insurance funds was a response to this vulnerability, and set a social pattern in industrialized nations that has continued for more than a century. The two principal ethical concepts associated with health insurance are social solidarity and social justice.

Health Insurance and Social Solidarity

As was evident in the European sickness funds, the insurance compact expresses an underlying solidarity among insurance pool subscribers. Persons facing a common vulnerability organize into a group whose shared resources, built up from relatively small individual contributions, will assist members who suffer financial loss as a result of illness or injury. Since the anticipated harm is a matter of probability, the group that pools its resources must be large enough and composed of persons with sufficiently variable risk levels so that, in a given period of time covered by the contributions (or premiums), only a minority of those at risk will actually experience illness or injury. The majority will contribute without needing to draw on the pooled resources. Those who do not encounter harm stand in a relationship of fiscal solidarity with those who do. The smaller the group, the more vulnerable it is to being overwhelmed by a small number of very large claims. If the group includes a large number of persons with high probability of need (the elderly, for example), a high level of member contributions will be required to guarantee adequate resources to cover every claim.

In addition to the purely fiscal relationship among contributors, reigning social and political ideas affect the conscious feelings of solidarity they experience as members of an insured group. Compulsory sickness insurance for workers, providing for both lost wages and the cost of medical care, was first organized at a national level in 1883 in Germany by the conservative chancellor Otto von Bismarck as a defensive maneuver against the rising influence of the German Social Democratic Party. As Paul Starr noted in his 1982 work, Bismarck believed workers were less likely to demand more radical reforms if certain harsh realities of the industrial revolution could be tempered with benevolence flowing from the monarchy.

In the closing decades of the nineteenth century, several other European nations took similar actions to protect workers' vulnerability, but the United States showed little interest in the idea until the Progressive reformers began to press the issue in the early years of the twentieth century (Hirshfield). They promoted compulsory health insurance as a form of enlightened self-interest on the part of the middle class: The survival of individual freedoms essential to capitalism required taming the tendency of free enterprise to pursue profit without concern for the precarious circumstance of wage laborers. Robert N. Bellah, et al. (1985) noted that the vocabulary of individualism typical of the culture of private consumption has shaped public discourse about health insurance in the United States, and the concept of social solidarity is only faintly evident in the debate that has evolved since the early twentieth century (Churchill).

In some societies, social consciousness about health insurance sees it as a component of the nation's system of social insurance—that is, a public guarantee that certain basic human needs will be met at some minimum level for all members of the community. This has typically been the meaning of health insurance in Western Europe. Conversely, health insurance may be seen as a marketable service properly residing in the private sector, which has been the dominant, though not unanimous, social understanding in the United States (Greenlick, 1988).

The Progressives' compulsory insurance campaign had failed prior to 1920, and by the late 1930s, the idea of voluntary health insurance for workers as a fringe benefit of employment had taken over as the prevailing rationale for social change. The appeal of voluntary insurance, supported by tax subsidies for employers and workers, was fully compatible with the Progressives' individual freedoms argument. Indeed, the voluntary approach seemed capable of solving the solidarity problem, as the percentage of the whole population with voluntary hospital insurance shot up from less than 10 percent in 1940 to 57 percent in 1950 and to nearly 90 percent by the early 1970s (Anderson). With health insurance spreading widely through the working community, yet systematically leaving those not in the workforce outside the fold, the idea of national health insurance based on explicit appeals to solidarity and social justice emerged periodically but each time failed to pass into law (Hirshfield; Starr).

Health Insurance, Social Justice, and Rights

The concept of justice is the second major ethical theme associated with health insurance. Concerns about justice and health insurance derive from the question whether it is fair for some, but not all, citizens to have insured access to healthcare. Originally, health insurance was viewed as required by social justice not for everyone, but only for those made vulnerable by the conditions of wage labor. Compulsory insurance schemes were designed to help capitalism by making the working class more secure. The U.S. middle class broadly committed itself to the voluntary purchase of health insurance when, as a means of winning better fringe benefits through collective bargaining (intensified under wage and price controls during World War II), getting health insurance as a benefit became a normative expectation of workers.

Once the idea of health insurance takes hold in a society and is widely believed to give access to a fundamental benefit of social existence, it comes to be seen as the way members of the society purchase their healthcare, not merely the way they protect themselves from potential financial loss. Having insurance and getting needed healthcare become closely linked in the logic of justice. (For an account of how social expectations give rise to the perception of entitlement and societal obligation, see the work of Michael Walzer.)

The idea of a right to healthcare as a requirement of social justice is intimately connected to the practice of collectively financed healthcare. The notion that healthcare might count among positive human rights derives from the widespread belief that healthcare successfully meets fundamental human needs, such as security, relief from suffering, prevention of premature death, and maintenance of functional capacity. (For a philosophical argument about the grounds and limits of universal entitlement, see Norman Daniels's work and Charles J. Dougherty's publication.) Creating legal protections for that right becomes a problem of political will.

The injection of rights language into political arguments about health insurance is itself evidence of the evolution of the concept and expansion of its original limited goal of protecting wage laborers from the effects of major illness. In the absence of a constitutional or statutory declaration of a right to healthcare, opinion leaders use human rights language to motivate members of society and to provoke legislative action aimed at helping persons whose needs are being ignored. While specific contractual rights to healthcare exist between insured persons and their insurance carriers, that is not what advocates of a right to healthcare have in mind. When reformers argue for a right to healthcare, they mean that basic relationships of solidarity and interdependence among all members of society create a societal obligation to ensure access to healthcare for all. (For a discussion of issues raised by rights discourse in relation to health insurance and access to healthcare, see the U.S. President's Commission Report, and the 1994 work edited by Audrey Chapman.)

During the second half of the twentieth century, aggregate expenditures for healthcare rose at such a dramatic rate that by the 1980s, cost control in healthcare became a central issue for reformers. However, the question of setting limits makes debate about a right to healthcare politically difficult. Unlike rights to liberty or the pursuit of happiness, which entail noninterference by others, a right to healthcare entails paying someone to provide costly services. By 1990, the need to speak of a limited right was clear to many leaders, although negative reaction to the idea of rationing healthcare led many to deny its necessity, and how to define limits was hotly debated (Strosberg). In 1989, the state of Oregon intensified the debate when it organized a unique social experiment to guarantee coverage to uninsured persons while setting limits on what would be covered based on a prioritized list of healthcare services (Garland, 1992, 1994, 2001).

Organization and Financing of Health Insurance

The fundamental concept of any form of insurance is risk sharing: A large number of people who face a common threat of harm (auto accident, fire damage, costs of treatment for illness or injury) share their risks by paying premiums to an insurer who promises to finance payments to those who in the future actually suffer misfortune. All members of the risk-sharing group get a sense of security in return for their contributions even if they do not receive specific insurance payments (as a result of being personally harmed).

Ethical issues in risk sharing through health insurance are shaped by the insurer's decisions about how to organize and finance the common fund that members of a group rely on for protection against potential financial loss. For example, insurers may organize risk-sharing pools among individual subscribers, various age groups, business firms, or labor organizations. Financing might be done through a single, community-wide premium or through variable premiums tied to past utilization, health-risk or ethnic group or age or gender. The European approach was to develop social insurance mechanisms, or sick funds, initiated by the public sector. In the United States, the free market casualty insurance model was adapted in a unique form to fulfill the social insurance function. The resulting hybrid fails to satisfy either free market norms or social insurance ideals.

The major development in U.S. health insurance in the 1930s and 1940s was led not by government or business but by nonprofit corporations such as Blue Cross (hospital insurance service corporations), Blue Shield (physician insurance service corporations), and a variety of consumer and producer cooperatives that provided coverage for hospital and medical services. The corporate missions and characteristics of these organizations gave U.S. health insurance a strong social insurance tendency without fully incorporating the European approach.

Because they believed that the nonprofit organizations' approach to health insurance violated the basic tenets of casualty insurance, commercial insurers initially showed no interest in this market (Iglehart). Casualty insurance assumes that a hazard insured against is measurable and not something the insured person wants (such as checkups or preventive services), or can control (such as pregnancy).

From the beginning in the United States strict casualty insurance principles were ignored. While health insurance protects subscribers from the financial impact of relatively rare high-cost medical services, plans commonly also cover many low-cost services used every year by most members of the insured group. The typical health insurance plan provided to employees of large corporations includes coverage for some ambulatory care costs (office visits, X-rays, and laboratory services) and the major portion of emergency room and hospital charges. About 80 percent of the population will use some ambulatory care services, while only 10 percent of the population will need hospital care in any given year.

By the time the commercial insurers overcame their suspicion of the field, the nonprofit insurers had already brought much social insurance philosophy into the market. Consequently, while the health insurance language includes many standard insurance terms ("adverse selection," "moral hazard," "product lines," "lives covered by plans"), leading the casual observer to conclude that the field is a traditional casualty insurance market, it is, in reality, a form of social insurance peculiar to the United States. However, the competitive practices of commercial insurers have led to widespread use of experience rating, which undermines the social insurance spirit by making health insurance more expensive for those in greatest need. Health insurance plans use three basic methods to protect subscribers: indemnity benefits, service benefits, or direct provision of service. Indemnity insurance, typical of commercial insurers, reimburses a patient for a portion of incurred medical expenditures. Service benefits, typical of nonprofit insurers, pay physicians and hospitals directly on behalf of subscribers. Health maintenance organizations, by contrast, actually organize and deliver services directly to their members at clinics and hospitals that the plans usually own and operate, paying for professional services by salary or contract, not on a fee-for-service basis.

In a widespread effort to control medical care costs in the 1990s, managed care systems, especially those who were not associated with organized delivery systems, used various discounting and risk-sharing reimbursement mechanisms to pay medical service providers. By 2000, providers and patients had grown increasingly unhappy with the restrictions imposed by managed care strategies and the organizations could claim little success in controlling medical costs (Levit, Smith, and Cowen). New strategies relied on shifting costs to patients and members of insurance plans (Draper, Hurley, and Lesser; Christianson, Parente, and Taylor; Trude, Christianson, and Lesser). Six major tendencies characterize the way U.S. health insurance adapted casualty insurance concepts to serve a social insurance function: leadership by nonprofit corporations; a gradual shift from financing based on equal shares (community-rated premiums) to financing based on unequal shares (experience-rated premiums); consumer preference for comprehensive benefits; use of service and indemnity methods of benefit definition; carriers' preference for group rather than individual marketing of plans; and persistent ambivalence in the general public about the role of government in health insurance.

NONPROFIT STATUS OF HEALTH INSURANCE PIONEERS. Because the pioneers in U.S. health insurance were nonprofit, charitable organizations, they were developed to provide a social function beyond creating a profit for shareholders or syndicate owners. However, the social objective was not always to benefit consumers. Blue Cross was first organized to provide for the financial survival of the American voluntary, nonprofit hospital system during the period of the Great Depression. Although organized medicine initially opposed the new insurance schemes as unwanted intrusions into the privacy of the patient-physician relationship, Blue Shield was eventually formed as a preventive measure to keep mechanisms for paying physicians under the direct control of organized medicine. Provider cooperative prepaid group practices, such as Kaiser Permanente, were formed because some reform-minded physicians believed that prepaid group practice was a more satisfying and socially responsible way to practice medicine.

These nonprofit institutions were chartered in the public domain and were guided by boards of directors who were reminded that they represented society at large, rather than a group of stockholders. The corporate cultures that emerged under this influence generally produced organizational behavior different from that found in commercial insurance companies (Greenlick, 1988). The nonprofit corporations possessed a sense of mission to the community, a sense nurtured by their close ties to community hospitals and physicians' organizations. In the 1970s, pressured by their large corporate customers to contain costs, the nonprofit insurers began to behave like their competitors, the commercial insurance companies, and moved from community rating of premiums to experience-rating practices. Consequently, premiums increased for high-risk groups, making it difficult for the most needy to maintain health insurance coverage.

COMMUNITY-RATED VERSUS EXPERIENCE-RATED PREMIUMS. In an institutionalization of the concept of solidarity, the pioneer U.S. health insurance organizations originally used community-rating principles to fund their programs. In pure community rating, the premium is set by estimating the required budget for the covered population for the next year and dividing the total budget by the number of people expected to be covered. The result is the premium charged to each member of the population for the coming year. Thus, all employers in an insurer's service area would be charged the same per capita premium for their employees.

By contrast, in an experience-rated system, the approach favored by commercial carriers, the most recent available claims experience is analyzed to define a risk profile for specific groups. These risk profiles are applied to the next year's expected total budget to calculate group-specific premiums. Experience rating increases the premiums for groups that include high-use subscribers and reduces premiums for groups that include infrequent users. Consequently, people with serious and chronic health problems, who most need the risk-sharing of health insurance, are forced to pay higher and higher premiums, until they can no longer afford the cost of coverage (Greenlick, 1989).

As experience rating became more common, people with preexisting health conditions were frequently excluded from insurance coverage. This led many states during the 1980s to create special high-risk pools for "uninsurables." The practice also made health insurance too expensive for thousands of firms with small numbers of workers, especially those where even one worker had recently experienced a high-cost illness episode. The shift toward experience rating by nonprofit insurers has led to a disturbing incongruity between a social policy that favors free market practices in U.S. health insurance and a prevailing public expectation that private health insurance should fulfill a social insurance function.

COMPREHENSIVE BENEFIT PACKAGES. Because pioneer health insurance organizations had among their objectives supporting the providers of care, they designed insurance plans based on comprehensive benefits that would cover not only infrequently needed high-cost services but also many low-cost services that might be used regularly by most subscribers. The idea of comprehensive benefits was very popular with the employees whose employers were paying most, or all, of the premiums for health insurance. This popularity was supported by the post-World War II belief that economic growth could permanently keep pace with new demands. During the 1960s and 1970s, most Blue Cross Blue Shield and prepaid group practice plans covered, with little deductible or coinsurance cost to the insured, most of the costs of physician, laboratory, X-ray, emergency room, and hospital medical and surgical services. During the 1970s, insurers increasingly added coverage for prescription drugs. To keep pace, commercial insurance companies increased the breadth and depth of their coverage, particularly for low-risk groups.

The preference for comprehensive benefits contributed to the explosive rate of growth in the health services industry during the postwar era. In 1940 healthcare accounted for 4.1 percent of the gross national product (GNP). It had expanded to 7.2 percent by 1970, reaching 10.7 percent in 1985 (Eastaugh). By the late 1970s, a chronic sense of crisis afflicted business and government administrators of health insurance budgets. Cost-containment strategies that used deductibles and coinsurance to reduce the use of health services by insured persons achieved only modest success. However, these typical casualty insurance mechanisms conflicted with the social insurance function of health insurance and were hotly debated among health insurance reformers in the early 1990s.

SERVICE BENEFITS VERSUS INDEMNITY BENEFITS. A distinguishing characteristic of the Blue Cross/Blue Shield programs and the prepaid group practices is that they sell their customers a promise to provide medical care services (service benefits) rather than a promise to reimburse incurred expenses (indemnity benefits). Service benefit organizations concern themselves with issues of delivery of care more than indemnity insurers, who cover only a specified portion of medical care expenses.

Preferred provider organizations (PPOs) and multiple forms of health maintenance organizations (HMOs) emerged from the cost-controlling strategies of the 1970s and 1980s. These service-delivery reforms sought cost savings through peer group review of practice patterns, favoring those that produced effective care while reducing frequency and length of hospitalizations, using fewer repeat visits, and increasing the use of outpatient care in place of costly hospital services.U.S. insurers took a hand in designing and administering these delivery system reforms, giving them a significant role in healthcare that went far beyond merely paying the bills.

GROUP ENROLLMENT VERSUS INDIVIDUAL MARKETING. Like the European social insurance movement, the development of health insurance in the United States was based on enrollment through employment groups. As more Americans left rural occupations and moved to the cities during and after the Great Depression of the 1930s, they found work in large industrial companies that increasingly offered comprehensive health insurance coverage as a fringe benefit of employment. The health insurance industry focused on enrolling members through work groups. As long as employment in these industries grew, so did the proportion of U.S. citizens covered by health insurance. Labor market forces seemed to be producing social insurance goals without the need of centralized decisions.

Employment-based group enrollment ultimately comes up short from the social insurance perspective, however, since many persons with significant healthcare needs are not in the work force and will not have access to health insurance. This way of distributing health insurance leaves workers doubly vulnerable to fluctuations in the labor market: Low-wage jobs frequently do not include health insurance benefits, and business cycles or industry competition may cause work force reductions leading to loss of health insurance for employees and their dependents (homemakers and children).

Inequities in the labor market carry over to health insurance when employment is the basis for its distribution (Jecker). Women's groups argue that healthcare services important to women, such as mammography, have tended not to be covered. Women who work are less likely than men who work to have employer or union contributions to their insurance. Women are also more likely to work part-time and receive no fringe benefits. Women are less likely to belong to a labor union and they change jobs more frequently than men, making them more vulnerable to preexisting condition exclusions from insurance. Women predominate in low-paying jobs where insurance is usually not offered as a benefit. Many of these distribution inequities also affect minorities, leading some reformers to argue for uncoupling health insurance from employment.

After vigorous growth between 1940 and 1960, the employment-based system had generated health insurance coverage for nearly 70 percent of the population under sixty-five, while only slightly more than 40 percent of the elderly were covered, leading to the establishment of Medicare and Medicaid in 1965 (Anderson). These two programs brought health insurance protection to virtually all of the elderly, and to a significant proportion of those living in poverty, as well. They did not, however, provide coverage for everyone, so that the United States entered the 1990s with more than thirty million citizens having no health insurance. This fueled a vigorous revival of interest in a national health insurance program capable of guaranteeing coverage for every citizen.

During the 1980s, self-insurance emerged as a cost-control strategy among large corporations. These firms stopped buying health insurance for their workers and set themselves up as the at-risk entity for healthcare costs incurred by their employees. The practice put these corporations beyond the reach of state insurance regulations because of a 1974 federal law, the Employee Retirement Income Security Act (ERISA). The intent of ERISA was to protect pension trust funds in companies with employees in several states from inconsistent and burdensome state regulations. The effect on health insurance, while not a primary goal of ERISA, so complicated health-insurance reform that, by the late 1980s, it became a critical element in all proposals that relied on employee benefits as the primary vehicle for distributing health insurance to citizens.

At the beginning of the twenty-first century, the concept of defined contribution to employee benefit packages (rather than defined benefits) became popular among free market reformers (Christianson et al.). This concept responded to employers' desire to be less involved in insurance purchasing and shift decision making to their employees. The strategy combined a set amount of employer contribution with a responsibility on employees to purchase their own health insurance. Employees could use a portion of the defined contribution for direct purchase of services. In the final analysis, employees in such a plan would be individually responsible to cover the costs of their care with a combination of out-of-pocket spending, insurance protection, and limited access to the defined contribution pool created by the employer. This approach can be understood as an effort to deemphasize the social insurance model by insisting on increased consumer responsibility for non-catastrophic healthcare needs.

The Government Role in U.S. Health Insurance

The U.S. government has had a role in health insurance since the eighteenth century, when it accepted the responsibility to provide medical care for the U.S. Merchant Marine. During the growth period of private health insurance in the United States prior to Medicare and Medicaid (1940–1965), the federal government let the private market work, limiting itself to indirect involvement through tax incentives for employers and employees who favored the purchase of health insurance as a fringe benefit. State and local governments were expected to provide care to the indigent and to the mentally ill. As a large employer, the federal government became a major purchaser of health insurance for its employees.

Finally, the federal government is a major supplier of social insurance for medical care for Native Americans, active-duty military personnel and their dependents, and veterans. The total public expenditure for medical care services in 2000 was $590 billion, 45 percent of the $1.3 trillion total national expenditure for health services and supplies during the year.

Government involvement in U.S. health insurance differs distinctly from paths followed by most other industrial nations. In Europe, several nations have made the direct delivery of healthcare a national government responsibility (e.g., the United Kingdom and the Scandinavian countries); others have taken up the role of coordination in mixed public-private systems (e.g., Germany, the Netherlands, Switzerland); others have assumed the role of providing health insurance to the citizenry, allowing hospitals and physicians to operate in a fee-for-service environment (France).

In the late 1960s, Canada adopted an approach similar to France's: Each province has a monopoly on health insurance for basic services, while the federal government plays a coordinating role. Canadian Medicare rests on five essential principles: universal entitlement, accessibility of services, comprehensive benefits, portability of benefits across provincial boundaries, and public administration of the system within each province.

Questions about the proper role of government in health insurance continue to be central issues in debates among U.S. health insurance reformers. Proposals put forward in the first decade of the twenty-first century will succeed or fail on the basis of their ability to make the case that they have found an acceptable balance point on the public-private continuum where private markets (insurance carriers, providers, suppliers) come together under public policy constraints to produce an acknowledged common good.

Conclusion

As the twenty-first century dawned, the evolution of health insurance in the United States and elsewhere had reached a point where significant new public policy decisions were increasingly demanded by the consumer groups, business, politicians, and health professionals (see Rashi Fein's work). In all industrial nations, the rates of growth in total expenditures for healthcare were creating economic strains and social concern (see the report of the Government Committee on Choices in Healthcare). Particularly in the United States—with the highest percentage of its GNP devoted to healthcare—business, government, and consumer groups insisted on effective control of total healthcare expenditures. Some argued that the solution had to come from submitting healthcare to a competitive market. Others preferred government regulation through global budgets, delivery system reforms, and limitations on services that qualify for collective financing. Most reformers insisted that health insurance had to stop fueling uncontrolled growth in healthcare spending.

Expenditure control has major consequences for the social insurance aspect of health insurance schemes. Many European nations and Canada have sought to control total expenditures without sacrificing the healthcare component of their social insurance commitments. In the United States, many providers, social reformers, and the general public have demanded explicit commitment to the social insurance dimension of health insurance: a universal system that would guarantee a decent minimum of healthcare to every citizen. Reformers were particularly concerned to have the nation address the equity issue. During a thirty-two-month period in 1990–1992, one-fourth of the entire population outside of institutions were without health insurance for at least one month; more than one-third of the African-American population and nearly one-half of the Hispanic population found themselves excluded from coverage (Pear).

Growing public awareness of the size of the uninsured population and the vulnerability of the middle class to loss of job-related health insurance have led to growing dissatisfaction with the system and sparked a renewed interest in health insurance reform. Dozens of proposals emerged in the late 1980s and 1990s driven by several key questions. Should America continue its multiple payer, public-private system, or embark on a new path with a streamlined single-payer system? Should the single payer be the federal government or each state? If there were to be multiple payers, who would conduct the negotiations needed to coordinate their practices so that universal coverage would be achieved and maintained?

The multiple-payer approach continues the path of adapting casualty insurance and free-market forces to serve the social insurance function. In the mid-1990s, President Bill Clinton proposed a market-structuring, multiple-payer solution (White House Domestic Policy Council; Zelman), and was immediately criticized by sponsors of competing market proposals for interfering too much with market forces and not trusting them to achieve efficient allocations (Enthoven and Singer). Single-payer advocates, arguing that Clinton was fundamentally mistaken and that the private health insurance market was simply the wrong vehicle for achieving universal coverage and cost control, invoked the social insurance model, abandoning market pluralism in favor of uncomplicated universality and administrative efficiency achievable through centralized financing.

Finally, the Clinton proposal failed politically. Backing away from universal coverage, the Clinton Administration launched a special program to increase children's access to coverage in 1997 (Title XXI of the Social Security Act, the State Children's Health Insurance Program). By 1999, all fifty states had approved programs that either created a special program for children, an expansion of Medicaid, or some combination of the two. Despite success in reaching children, the percentage of Americans without health insurance has grown, costs have not come under control, and the critics of the status quo remain unable to attract sufficient political consensus to bring about universal coverage.

Health insurance in the United States continues to evolve. The tension between the casualty insurance practices and social insurance ideals frustrate reformers in both camps. The enduring challenge is to formulate policies that can control total expenditures while allocating resources fairly and promoting the common good.

michael j. garland

merwyn r. greenlick (1995)

revised by authors

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