After the success of Blue Cross and Blue Shield in the 1930s, continued growth in the market occurred for several reasons. The supply of health insurance increased once commercial insurance companies decided to enter the market for health coverage. Demand for health insurance increased as medical technology further advanced, and as government policies encouraged the popularity of health insurance as a form of employee compensation.
Blue Cross and Blue Shield were first to enter the health insurance market because commercial insurance companies were reluctant to even offer health insurance early in the century. As previously mentioned, they feared that they would not be able to overcome problems relating to adverse selection, so that offering health insurance would not be profitable. The success of Blue Cross and Blue Shield showed just how easily adverse selection problems could be overcome: by focusing on providing health insurance only to groups of employed workers. This would allow commercial insurance companies to avoid adverse selection because they would insure relatively young, healthy people who did not individually seek health insurance. After viewing the success of Blue Cross and Blue Shield, commercial health insurance companies began to move rapidly into the health insurance market. As shown in Figure 1, the market for health insurance exploded in size in the 1940s, growing from a total enrollment of 20,662,000 in 1940 to nearly 142,334,000 in 1950 (Health Insurance Institute 1961, Source Book, p. 10). As the Superintendent of Insurance in New York, Louis H. Pink, noted in 1939
... There are twenty stock insurance companies which are today issuing in this state Individual Medical Reimbursement, Hospitalization, and Sickness Expense Policies. About half of these have only recently gone into this field. It is no doubt the interest aroused by the non-profit associations which has induced the regular insurance companies to extend their activities in this way (Pink 1939).
Figure 1: Number of Persons with Health Insurance (thousands), 1940-1960
Source: Source Book of Health Insurance Data, 1965.
Community Rating versus Experience Rating
The success of commercial companies was aided by two factors. First, the competitiveness of Blue Cross and Blue Shield was limited by the fact that their non-profit status required that they community rate their policies. Under a system of community rating, insurance companies charge the same premium to sicker people as they do to healthy people. Since they were not considered to be nonprofit organizations, commercial insurance companies were not required to community rate their policies. Instead, commercial insurance companies could engage in experience rating, whereby they charged sicker people higher premiums and healthier people lower premiums. As a result, commercial companies could often offer relatively healthy groups lower premiums than the Blue Cross and Blue Shield plans, and gain their business. Thus, the commercial health insurance business boomed, as shown in Figure 2.
Figure 2: Enrollment in Commercial Insurance Plans v. Blue Cross and Blue Shield
Source: Source Book of Health Insurance Data, 1965.
Figure 2 illustrates the growth of commercial insurance relative to Blue Cross and Blue Shield. So successful was commercial insurance that by the early 1950s, commercial plans had more subscribers than Blue Cross and Blue Shield. In 1951, 41.5 million people were enrolled in group or individual hospital insurance plans offered by commercial insurance companies, while only 40.9 million people were enrolled in Blue Cross and Blue Shield plans (Health Insurance Institute 1965, Source Book, p. 14).
Growth in Demand: Government Policies that Encouraged Health Insurance
Offering insurance policies to employee groups not only benefited insurers, but also benefited employers. During World War II, wage and price controls prevented employers from using wages to compete for scarce labor. Under the 1942 Stabilization Act, Congress limited the wage increases that could be offered by firms, but permitted the adoption of employee insurance plans. In this way, health benefit packages offered one means of securing workers. In the 1940s, two major rulings also reinforced the foundation of the employer-provided health insurance system. First, in 1945 the War Labor Board ruled that employers could not modify or cancel group insurance plans during the contract period. Then, in 1949, the National Labor Relations Board ruled in a dispute between the Inland Steel Co. and the United Steelworkers Union that the term "wages" included pension and insurance benefits. Therefore, when negotiating for wages, the union was allowed to negotiate benefit packages on behalf of workers as well. This ruling, affirmed later by the U.S. Supreme Court, further reinforced the employment-based system.5
Perhaps the most influential aspect of government intervention that shaped the employer-based system of health insurance was the tax treatment of employer-provided contributions to employee health insurance plans. First, employers did not have to pay payroll tax on their contributions to employee health plans. Further, under certain circumstances, employees did not have to pay income tax on their employer's contributions to their health insurance plans. The first such exclusion occurred under an administrative ruling handed down in 1943 which stated that payments made by the employer directly to commercial insurance companies for group medical and hospitalization premiums of employees were not taxable as employee income (Yale Law Journal, 1954, pp. 222-247). While this particular ruling was highly restrictive and limited in its applicability, it was codified and extended in 1954. Under the 1954 Internal Revenue Code (IRC), employer contributions to employee health plans were exempt from employee taxable income. As a result of this tax-advantaged form of compensation, the demand for health insurance further increased throughout the 1950s (Thomasson 2003).
