Ensuring America’s Health: The Public Creation of the Corporate Health Care System by Christy Ford Chapin (review)

Chapin applies the results of considerable research in primary and secondary sources in order to assert and sustain a polemical thesis about the history of health care policy in the United States. She elaborates this thesis in an introduction, seven chapters, and an epilogue.

Over the past century, Chapin argues, an “insurance company model” for financing health services has been promoted by leaders of nonprofit and commercial insurance companies and of the medical profession, often allied with hospital executives as well as with powerful policy makers in the executive and legislative branches of the federal government and many states. The implementation of this model has “evaded the correctional forces intrinsic” to both “free enterprise and government control” (p. 156). She regrets that, as a result of this history, the country has missed opportunities—most recently in enacting the Affordable Care Act of 2010—to achieve a “nationalized, universal system [through] a government-managed plan . . . using regulations and mandates to enfeeble and eventually drive out private coverage” (p. 245).

Readers are likely to make diverse judgments about Chapin’s polemic as well as about whether or not it is appropriate for it to dominate a book that its author and eminent academic publisher put forward as a work of peer-reviewed history. This reviewer prefers to contextualize rather than to judge, however. Chapin’s book revives a reformist bias that, between the 1920s and 1960s, influenced considerable scholarship about health care by historians and scholars of economics, political science, public health, and law. The influence of this bias on scholarly publications has been in sharp decline since the 1960s, as a result of changing assumptions about methodology and the relationship between research and advocacy, as well as changes in the sources of funding for research on health services and policy.

Instead of judging Chapin’s polemic, I will describe aspects of her research that contribute to the historical literature, limitations to her knowledge of relevant secondary sources, and errors or omissions of facts that are documented by primary sources.

Chapin contributes to historical knowledge about several critical episodes in the politics of policy making for health in the United States. These episodes include the failure of the Eisenhower administration to enact a reinsurance program; the rising and then declining influence of the American Medical Association (AMA) on health policy between the 1910s and the 1960s; the history of commercial health insurance between the 1940s and 1970s; and the history of the influence of Blue Cross and Blue Shield organizations on the structure, processes, outcomes, and financing of health care.

Nevertheless, Chapin ignores relevant secondary sources on significant issues. A notable example is the extensive literature on the history of federal policy establishing and extending tax expenditures (sometimes called, oversimply, tax exclusions and exemptions) for health insurance as a benefit of employment. Another is the literature about the history of medical education and its relationship to continuity and change in the organization and content of clinical services.

Chapin’s numerous errors and omissions include claiming, anachronistically, that “physicians continued to promote erroneous ideas about illness” (p. 13) before most of these ideas had been falsified by scientific research; asserting that “nonprofit foundations . . . funded” (p. 15) the Flexner report of 1910, which was commissioned by the Carnegie Foundation for the Advancement of Teaching; quoting Ray Lyman Wilbur, an eminent medical school dean (at Stanford), secretary of the Treasury under President Coolidge, and past president of the AMA, as opposing any reform of the organization and financing of care in 1924 (pp. 21–22), when Wilbur became a prominent advocate of prepaid group practice only a few years later; ignoring the refusal, in 1938, of a federal official proposing a national system of universal coverage to negotiate with the AMA about other issues on their list of recommendations (pp. 25–26); and indicting “private interests” for defeating...