The Blues: A History of the Blue Cross and Blue Shield System, and: … And the Pursuit of National Health: The Incremental Strategy toward National Health Insurance in the United States of America (review)

Robert Cunningham III and Robert M. Cunningham, Jr. The Blues: A History of the Blue Cross and Blue Shield System. DeKalb: Northern Illinois University Press, 1997. xii + 311 pp. Ill. $36.00.

Jaap Kooijman. ... And the Pursuit of National Health: The Incremental Strategy toward National Health Insurance in the United States of America. Amsterdam Monographs in American Studies, no. 8. Amsterdam: Editions Rodopi, 1999. xi + 262 pp. $44.00; Hfl. 80.00 (cloth); F. 240.00; £26.00 (paperbound).

Policymakers in Washington, D.C., and elsewhere do not often rely on historians for policy advice. However, two recently published books should be required reading for all health-policy students because they document how the current health-policy debates are constrained by economic and political decisions made years ago. The Blues, by Robert Cunningham III and Robert M. Cunningham, Jr., traces the evolution of private health insurance in America. ... And the Pursuit of National Health, by Jaap Kooijman, focuses on the key political decisions made in the past century not to enact universal insurance. Both books are carefully researched and describe in detail the political maneuverings, the economic constraints, the personalities, and the political environment surrounding the evolution of health insurance coverage in the United States during the twentieth century.

When we first received these two volumes, we were concerned about their objectivity. The Blues was sponsored by the Blue Cross Association, and most of it was written by a longtime employee of Blue Cross. ... And the Pursuit of National Health was written by a scholar from the Netherlands who wondered why the United States does not have universal coverage; its cover shows an uninsured tuberculosis-stricken coal miner's wife. We soon discovered, however, that these are not partisan railings against the lack of universal health insurance coverage, or a defense of a market-based private health-insurance system. Kooijman explains, from a European perspective, America's unique path in the health-care arena, describing the reasons and circumstances that prevented universal health insurance from gathering enough political steam to be enacted. The Cunninghams' book explains how Blue Cross gradually filled a void that public health insurance was not filling.

For policy analysts, the most interesting component of both books could be the realization that decisions made seventy years ago are shaping the political debate of today. When Justin Ford Kimball began the prototype Blue Cross program in Dallas, Texas in 1929, he laid the cornerstone for the mainly private health-insurance system we have today. When the Roosevelt administration made the decision to eliminate a national health-insurance program from the Social Security Act, the resulting gap was rapidly filled by Blue Cross and Blue Shield Plans, and then other private insurers. These organizations developed a strong economic interest in maintaining the status quo: if private insurers did their job well, the majority of Americans would be satisfied with the current health system and would not want major changes.

Organized medicine, particularly the American Medical Association (AMA), plays a leading role in both books. When in 1932 Morris Fishbein, the influential former editor of the Journal of the American Medical Association, decried the recommendation of the Committee on the Costs of Medical Care (CCMC) for voluntary but universally accessible health insurance as "socialism and communism--inciting to revolution" (Kooijman, p. 37), he struck a note that would resound each time government health insurance was proposed. As stated by the AMA in 1934, the key concerns of the physicians were (1) control of medical service by the medical profession; (2) no third-party intervention in the physician-patient relationship; and (3...