Timothy Noah: A short history of health care





[Timothy Noah is a senior writer at Slate.]

... What we recognize as modern medicine, [Jonathan] Cohn writes [in Sick: The Untold Story of America's Health Care Crisis—And the People Who Paid the Price], began in the 1920s. That's when doctors and hospitals, having only during the previous decade learned enough about disease that they could be reliably helpful in treating sick people, began charging more than most individuals could easily pay. To close this gap, which worsened with the advent of the Great Depression, the administrator of Baylor Hospital in Dallas created a system that caught on elsewhere and eventually evolved into Blue Cross. The Blues were essentially nonprofit health insurers who served local community organizations like the Elks. In exchange for a tax break, Blue Cross organizations kept premiums reasonably low.

The success of the Blues persuaded commercial insurers, who initially considered medicine an unpromising market, to enter the field. Private insurers accelerated these efforts in the 1940s when businesses, seeking ways to get around wartime wage controls, began to compete for labor by offering health insurance. If government regulators had thought to freeze fringe benefits along with wages, we might have avoided making the workplace primarily responsible for supplying health insurance, a role that most people now agree was ill-advised. Instead, the government jumped on the bandwagon by exempting from the income tax company expenses associated with health care. (President Bush's proposal to alter this subsidy so that tax treatment of the self-employed is the same as for people who work for large companies—who currently enjoy an advantage—deserves praise for its progressivity. It would probably accelerate the business world's withdrawal from health insurance, which is inevitable. The trouble is, Bush offers no alternative to the workplace as a supplier of health insurance. Like Bush's plan to overthrow Saddam, it's great on the front end and disastrous on the back end.)

The Blues, in their early days, charged everyone the same premium, regardless of age, sex, or pre-existing conditions. This was partly because the Blues were quasi-philanthropic organizations, Cohn explains, and partly because the Blues were created by hospitals and therefore interested mainly in signing up potential hospital patients. They were sufficiently benevolent that when Harry Truman proposed a national health-care scheme, opponents were able to defeat it by arguing that the nonprofit sector had the problem well in hand. As private insurers entered the market, however, they rejiggered premiums by calculating relative risk, and avoided the riskiest potential customers altogether. To survive, the Blues followed suit; today, they no longer enjoy a tax advantage and are virtually indistinguishable from other health insurers. Meanwhile, large companies, which tend to employ significantly more young people than old people, began to self-insure. The combined result was that people who really needed health care had an increasingly difficult time affording, or even getting, health-care insurance....


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