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

Christy Ford Chapin’s Ensuring America’s Health: The Public Creation of the Corporate Health System is a study of the sometimes unappetizing process of creating the United States’ twentieth-century health care policy. Chapin focuses her analysis on three institutional forces—the American Medical Association (AMA), insurance companies, and the federal government—and how they have interacted to create an inefficient system based on the insurance company model. There was no master plan, according to Chapin, as leaders within the AMA during the first half of the century allied their organization with private insurance companies as a way of staving off perceived government encroachment of health care. By mid-century, this had created an “air of naturalness and inevitability” (p. 9) to the insurance company model of health care that helped cement its place in American medicine. Add to this governmental pressure to expand health care and the creation of public subsidies, such Medicare, and by the 1960s America was saddled with a system characterized by its “high costs, fragmented care, and corporate arrangements” (p. 4).

Chapin uses four themes to guide her analysis of health care policy. The first addresses the public–private interaction between the state and insurance companies characterized by “soft corporatism” (p. 8), in which the government’s influence was more moral than outright legislative. The second theme is how private insurance companies, thanks largely to their early alliance with the AMA, became the norm around which the government built its health care policies, most notably Medicare. Her third theme explores how the AMA’s early endorsement lent the insurance company model of health care public credibility, despite its inefficiencies. The final theme examines how the interactions among the AMA, insurance companies, and the government affected each of the groups involved. Herein Chapin names winners and losers. Insurance companies come out as undisputed winners, entrenched in the health care system thanks to policies such as Medicare and, more recently, the Affordable Care Act. The AMA and the physicians it represents come out as clear losers, as their goal of professional sovereignty gave way to the reality of insurance company management and government funding guidelines. Ultimately, according to Chapin, the American people are the biggest losers, as they must contend with a health system that is expensive, inefficient, and highly complicated to navigate.

Chapin’s sources come from the golden age of American bureaucracy, as institutions such as the AMA, Blue Cross and Blue Shield, and the United States government were undergoing top-down transformations that led them to become the institutions we recognize today. Corporate archives provide a fascinating body of evidence that documents the inner workings of how nongovernmental policy developed within the AMA and the insurance industry, and the national archives provide the material to document federal policy development. The strength of Chapin’s analysis is how she identifies the fingerprints of one group on another, thus illustrating the give-and-take within the public–private partnership that has produced the American health care system. The influence of charisma is not lost on Chapin, as she employs the personal papers of AMA leaders to identify the ways in which powerful individuals were able to forge policy for an entire profession.

Fans of policy will find Ensuring America’s Health a fascinating read, as Chapin excels at detailing the nitty-gritty of policy formation. She traces the rise of the Health Insurance Association of America as an effective behind-the-scenes lobbying group that avoided the limelight, cognizant of the fact that Americans generally distrust insurance companies. Chapin also follows the development of Blue Cross and Blue Shield as hospital- and physician-led alternatives to third-party insurance companies, and how these organizations failed to gain much support from AMA leadership. President Truman’s aborted health care initiative is also covered, with Chapin arguing that it was not ineffectual, as...