The Rise and Fall of HMOs: An American Health Care Revolution (review)

Jan Coombs has written two books under a single title. One is a history of the Marshfield Clinic, a large medical group practice that became a pioneering rural Health Maintenance Organization (HMO) in response to incentives offered by the federal government since the 1970s; the other is a history of health-care policy in the United States during the past seventy years, and especially the last three decades.

Coombs's history of the Marshfield Clinic contributes to the interdisciplinary literature on the history and operations of health-care organizations. Using archival sources and information from interviews that she conducted, she describes the effects on the clinic of competing opinions concerning the organization and delivery of health services, of the goals and management style of key individuals, and of federal and state policy. Her general history of health policy is less successful. She has read widely in recent history, but she uses these sources to justify her opinions about how Americans ought to behave, and on public officials. She berates Americans—apparently all of us—for tolerating a "misguided, wasteful system that leaves so many disadvantaged Americans groveling for scrapes [sic] of care" (p. 291). Moreover, government is incompetent to address "health care problems" because "public programs operate at cross-purposes from one another, protected by administrators intent on guarding their own turf" (pp. 74–75). These broad and controversial opinions seem out of place in a book that an author and a university press put forward as meeting the standards of scholarship.

The author occasionally blames health-care organizations for operating within constraints over which they actually had no control. For instance, she writes that "most HMOs failed the social test of accessibility in the 1970s because they marketed policies only to employee groups" (p. 125). Two paragraphs later, however, she admits that few people who were not members of groups could afford to purchase coverage from HMOs, "even though prepaid plans were often less costly than traditional insurance policies" (p. 125).

Some of Coombs's facts are wrong. She writes that in 1934 Franklin D. Roosevelt "asked Isidore Falk and Edgar Sydenstricker to help him draft" the health insurance provisions of what became the Social Security Act (p. 5). According to several historians, however, Roosevelt had decided to omit health insurance from Social Security; a senior official who hoped to persuade the president to change his mind asked a foundation to send two employees, Falk and Sydenstricker, to help the committee that was drafting the report that preceded the Social Security Act. Coombs also claims, contrary to the literature, that Congress seriously considered legislation for comprehensive national health insurance in 1968 (p. 14). A final example: she says that "self-insured plans were more expensive than purchased [that is, commercial and risk-based] policies" (p. 137)—a statement that would surprise decision makers in firms that employ the majority of Americans who have health benefits.