Blue Cross: Hospital Insurance
As the demand for hospital care increased in the 1920s, a new payment innovation developed at the end of the decade that would revolutionize the market for health insurance. The precursor to Blue Cross was founded in 1929 by a group of Dallas teachers who contracted with Baylor University Hospital to provide 21 days of hospitalization for a fixed $6.00 payment. The Baylor plan developed as a way to ensure that people paid their bills. One official connected with the plan compared hospital bills to cosmetics, noting that the nation's cosmetic bill was actually more than the nation's hospital bill, but that "We spend a dollar or so at a time for cosmetics and do not notice the high cost. The ribbon counter clerk can pay 50¢, 75¢, or $1 a month, yet.... it would take about twenty years to set aside a large hospital bill" (The American Foundation 1937, p. 1023).
Pre-paid hospital service plans grew over the course of the Great Depression. Pre-paid hospital care was mutually advantageous to both subscribers and hospitals during the early 1930s, when consumers and hospitals suffered from falling incomes. While the pre-paid plans allowed consumers to affordably pay for hospital care, they also benefited hospitals by providing them with a way to earn income during a time of falling hospital revenue. Only 62 percent of beds in private hospitals were occupied on average, compared to 89 percent of beds in public hospitals that accepted charity care (Davis and Rorem 1932, p. 5). As one pediatrician in the Midwest noted, "Things went swimmingly as long as endowed funds allowed the hospitals to carry on. When the funds from endowments disappeared the hospitals got into trouble and thus the various plans to help the hospitals financially developed" (American Foundation 1937, p. 756).
The American Hospital Association (AHA) encouraged hospitals in such endeavors ostensibly as a means of relieving "... from financial embarrassment and even from disaster in the emergency of sickness those who are in receipt of limited incomes" (Reed 1947, p. 14). However, the prepayment plans also clearly benefited hospitals by giving them a constant stream of income. Since single-hospital plans generated greater competition among hospitals, community hospitals began to organize with each other to offer hospital coverage and to reduce inter-hospital competition. These plans eventually combined under the auspices of the AHA under the name Blue Cross.
Blue Cross Designed to Reduce Price Competition among Hospitals
The AHA designed the Blue Cross guidelines so as to reduce price competition among hospitals. Prepayment plans seeking the Blue Cross designation had to provide subscribers with free choice of physician and hospital, a requirement that eliminated single-hospital plans from consideration. Blue Cross plans also benefited from special state-level enabling legislation allowing them to act as non-profit corporations, to enjoy tax-exempt status, and to be free from the usual insurance regulations. Originally, the reason for this exemption was that Blue Cross plans were considered to be in society's best interest since they often provided benefits to low-income individuals (Eilers 1963, p. 82). Without the enabling legislation, Blue Cross plans would have had to organize under the laws for insurance companies. If they organized as stock companies, the plans would have had to meet reserve requirements to ensure their solvency. Organizing as mutual companies meant that they would either have to meet reserve requirements or be subject to assessment liability.3 Given that most plans had little financial resources available to them, they would not have been able to meet the requirements.
The enabling legislation freed the plans from the traditional insurance reserve requirements because the Blue Cross plans were underwritten by hospitals. Hospitals contracted with the plans to provide subscriber services, and agreed to provide service benefits even during periods when the plans lacked funds to provide reimbursement. Under the enabling legislation, the plans "enjoy the advantages of exemption from the regular insurance laws of the state, are freed from the obligation of maintaining the high reserves required of commercial insurance companies and are relieved of paying taxes" (Anderson 1944, p. 11).4 Enabling laws served to increase the amount of health insurance sold in states in which they were implemented, causing growth in the market (Thomasson 2002).
Blue Shield: Insurance for Physician Services
Despite the success of Blue Cross and pre-paid hospitalization policies, physicians were much slower in providing pre-paid care. Blue Cross and Blue Shield developed separately, with little coordination between them (McDavitt 1946). Physicians worried that a third-party system of payment would lower their incomes by interfering with the physician-patient relationship and restricting the ability of physicians to price discriminate. However, in the 1930s, physicians were faced with two situations that spurred them to develop their own pre-paid plans. First, Blue Cross plans were becoming popular, and some physicians feared that hospitals would move into the realm of providing insurance for physician services, thus limiting physician autonomy. In addition, advocates of compulsory health insurance looked to the emerging social security legislation as a logical means of providing national health care. Compulsory health insurance was even more anathema to physicians than voluntary health insurance. It became clear to physicians that in order to protect their interests, they would be better off pre-empting both hospitals and compulsory insurance proponents by sculpting their own plan.
Thus, to protect themselves from competition with Blue Cross, as well as to provide an alternative to compulsory insurance, physicians began to organize a framework for pre-paid plans that covered physician services. In this regard, the American Medical Association (AMA) adopted a set of ten principles in 1934 "... which were apparently promulgated for the primary purposes of preventing hospital service plans from underwriting physician services and providing an answer to the proponents of compulsory medical insurance" (Hedinger 1966, p. 82). Within these rules were provisions that ensured that voluntary health insurance would remain under physician supervision and not be subject to the control of non-physicians. In addition, physicians wanted to retain their ability to price discriminate (to charge different rates to different customers, based on their ability to pay).
These principles were reflected in the actions of physicians as they established enabling legislation similar to that which allowed Blue Cross plans to operate as non-profits. Like the Blue Cross enabling legislation, these laws allowed Blue Shield plans to be tax-exempt and free from the provisions of insurance statutes. Physicians lobbied to ensure that they would be represented on the boards of all such plans, and acted to ensure that all plans required free choice of physician. In 1939, the California Physicians' Service (CPS) began to operate as the first prepayment plan designed to cover physicians' services. Open to employees earning less than $3,000 annually, the CPS provided physicians' services to employee groups for the fee of $1.70 per month for employees (Scofea, p. 5). To further these efforts, the AMA encouraged state and local medical societies to form their own prepayment plans. These physician-sponsored plans ultimately affiliated and became known as Blue Shield in 1946.
Blue Shield plans offered medical and surgical benefits for hospitalized members, although certain plans also covered visits to doctors' offices. While some plans were like the Blue Cross plans in that they offered service benefits to low-income subscribers (meaning that the plans directly reimbursed physicians for services), most Blue Shield plans operated on a mixed service-indemnity basis. Doctors charged patients who were subscribers to Blue Shield the difference between their actual charges and the amount for which they were reimbursed by Blue Shield. In this manner, doctors could retain their power to price discriminate by charging different prices to different patients.
