از بیماری تا سلامتی: توسعه قرن بیستم از بیمه سلامت ایالات متحده

This paper explores the institutional development of health insurance in the United States. By combining a qualitative history of the development of the market with an empirical analysis of a panel of health insurance data from 1931–1955, the paper identifies a number of factors that influenced the growth of the health insurance market. While demand factors such as increasing income and improvements in medical technology certainly contributed to the growth of the market, supply side factors were also important. There is evidence that hospitals may have contributed to the growth of health insurance as a means of smoothing revenues during the Great Depression. State-level policies that allowed the Blue Cross and Blue Shield plans to operate as nonprofits also spurred market growth, as did federal government policies that promoted the link between employment and health insurance.

By 1920, 16 European countries had adopted some form of nationalized, compulsory health insurance that provided income replacement and medical care in the event of accident or illness.2 In the United States, the market developed as a primarily private, employment-based system despite attempts to implement compulsory health insurance plans in the 1910s, 1930s, and 1940s. Modern health insurance did not develop in the United States until the late 1920s, and it was only after 1940 that the market experienced substantial growth. As shown in Fig. 1, only 12.3 million Americans had health insurance coverage in 1940, but the market exploded in size in the 1940s and 1950s. By 1960, 122.5 million 1 Many thanks to Bill Collins, George Davis, Price Fishback, Gerald Friedman, Bart Wilson, and seminar participants at North Carolina State University for providing excellent comments and suggestions. This paper benefited tremendously from the comments of two anonymous referees. Financial support from NSF Grant SBR-9632121 and a grant from the University of Arizona are gratefully acknowledged. All errors are my responsibility. 2 Germany established the first nationalized system of health insurance in 1883, followed by Austria (1888), Hungary (1891), Norway (1909), Serbia (1910), Britain (1911), Russia (1912), and the Netherlands (1913). See Millis, p. 50, or Starr, p. 237, for greater discussion.people—nearly 10 times the number covered in 1940—were enrolled in private health insurance plans (Source Book of Health Insurance Data, 1976–1977, p. 22).

This paper discusses and analyzes the forces that contributed to the initial development and growth of the U.S. market for health insurance. Results suggest that although the demand for health insurance rose during the first half of the century, supply innovations had a major impact on the initial development of the market. During the 1930s, hospitals developed an institutional innovation in the form of prepayment plans as they attempted to reduce interhospital competition and to smooth revenue uncertainty during the Great Depression. They were later joined by the doctors’ organizations that established the Blue Shield prepayment plans to provide coverage for nonhospital treatment. Once the Blues signaled the presence of a market for health insurance, commercial insurers joined thecompetition and found ways to lower prices through experience rating and selling group insurance. The supply-side innovations were aided greatly by specific government policies at the state level. The passage of enabling legislation that freed the Blues from insurance regulations led to significant increases in the sale of total health insurance even though the Blues became a smaller part of the market. This legislation had its cost, however, because it required the Blues to follow a community rating policy in setting their insurance premium rates. The requirement of community rating by the Blues opened the door for commercial insurers to compete by lowering their rates for lower-risk insurance purchasers. While supply-side forces played a significant role in shaping the early health insurance market, changes in demand also contributed to the expansion of the health market. Health insurance clearly was a normal good, as rising incomes helped to fuel the expansion of insurance. Government policy also influenced the demand side of the market. The wage controls imposed during World War II and the early favorable tax treatment of employer contributions to health insurance premiums (which was firmly established in 1954) contributed to the expansion of employment-based, group insurance (see Thomasson, 2000). Finally, there were also significant changes in factors that were not easily measured. In the empirical estimation the coefficients of the year dummies show a clear upward growth in the demand and supply for health insurance, even after controlling for income growth and other demand-side factors. The most plausible effect that the year dummies capture is that of the growth in medical technology and of the increasing awareness of medical technology among Americans. While this effect is not measurable, it no doubt contributed to an increase in the demand for health insurance during the late 1930s and 1940s. Considering both the measurable effects reflected in the supply and demand equations, as well as the effects captured in the individual year dummies, the growth of the health insurance market between 1930 and 1950 resulted from no single force, but rather the simultaneous occurrence of a number of factors. Starting from the prepayment schemes fostered by the hospitals in the early 1930s, health insurance grew into its own as improvements in medical technology stimulated the demand for health insurance, and insurance companies began offering insurance to employee groups. Government policy in the 1940s and 1950s reinforced this trend, and cemented the employer-based system of private health insurance that the United States has today.