Ensuring America's Health marks a significant contribution to a broad literature focused on how, over the course of the twentieth century, the United States health system became fragmented, costly, and inefficient. Christy Ford Chapin focuses on the advent of what she calls the “insurance company model,” shining a light on why insurance companies—thus far, generally understudied by historians—came to dominate the nation's health care marketplace.

Chapin mines transcripts of congressional hearings and debates, private correspondence of insurance company executives and prominent physicians, and business and medical journals, among other sources, telling her story mainly from the perspective of the American Medical Association (AMA), the Health Insurance Association of America (HIAA), and Blue Cross & Blue Shield. These actors, she demonstrates, gradually entrenched the insurance company model in the 1940s and 1950s. Initially motivated to grow the “voluntary” market by mutual opposition to federal involvement in health care, Chapin argues, the groups’ efforts yielded some paradoxical results, and a semblance of unified purpose began to dissipate in the 1960s. By that point, the AMA had squandered considerable cultural and political power, and doctors had lost much of their professional autonomy. Around the same time, Chapin asserts, insurance companies became a “third party,” with a vested interest in quietly working alongside, rather than against, policymakers on federally based reforms. The insurance company model had become so well established that it served as the scaffolding for federally sponsored programs like Medicare, passed in 1965.

Historians of business, health care, and medicine will be interested in Chapin's assertion that the mid-twentieth-century AMA was hardly well run, unified, or representative of the perspectives of many U.S. doctors. Rank-and-file members often found themselves at odds with older, conservative leaders, who disregarded consultants’ warnings against using polemical anticommunist rhetoric and their advice about how the association should publicly present itself. AMA membership peaked at about 75 percent of practicing doctors in the 1950s, Chapin says. By 1971, when fewer than 50 percent of U.S. doctors were affiliated with the association, membership levels were on a decidedly downward spiral. Evidently, scholars searching for the “doctor's perspective” on any given health policy of the mid-twentieth century and beyond must consider the AMA stance, but must also acknowledge that it was hardly representative of the entire profession.

Teachers of health policy and its history will likely find Chapin's chapter on the passage of Medicare useful. Although much of the story she tells about the roots of that program is relatively well known—its legislative origins years before passage, the arguments of those who fought for and against it—her account is succinct, and it includes the viewpoints of insurance company representatives, which are typically shrouded in some mystery. In this case, bringing a previously underexplored perspective to the fore was no small feat. Chapin notes that the HIAA made an effort to lobby for policies discreetly, since its representatives were aware that no politician wished to be associated with massive for-profit businesses that were viewed skeptically by the American public.

Looming in the background of this story are employers and unions. Chapin mentions important moments in the history of employer-sponsored health insurance—for example, she notes that General Electric was the first to offer comprehensive medical benefits in 1955. Those tidbits hint at the idea that a deeper exploration of interactions between insurance companies, business, and labor could yield interesting findings.

But Chapin makes it clear that the advent of the insurance company model is important not just because of what it reveals about perceptions of, and relations between, interest groups. It also deeply impacted the practice of medicine. The centrality of insurance companies in the administration of health care explains why, by midcentury, doctors became businesspeople, responsible for hiring staffs and running offices; they had to find ways to process the paperwork that insurance companies increasingly required. Chapin argues that doctors had some power to slow accelerating health care costs—for example, by refusing to perform unnecessary procedures—but doing so was hardly the norm. Importantly, Chapin maintains, the insurance company model accelerated a turn toward specialization, since insurance reimbursement rates were higher for practitioners who performed procedures—especially surgeries—than they were for general care doctors.

Chapin's story not only helps explain a tangle of events and parties that played a role in shaping present-day realities, but also highlights larger intricacies of the U.S. health care system and political process. Like others who have studied the public-private divide in the U.S. health care system, Chapin offers compelling evidence that the private sector—in this case, commercial and nonprofit health insurance plans—was directly impacted by major federal health policy proposals and, in turn, helped shape government programs.

Meanwhile, Chapin shows, there was little in the way of market “logic.” She notes that insurance company executives recognized as early as the 1930s that health insurance would be unwieldy and that costs would escalate. They recognized, in essence, that it made no rational sense. Right they were. Chapin shows that the insurance company model, in almost every way, never really worked, but it took hold nonetheless. Plans covered more and more people—eventually, middle- and high-income workers and the elderly—and offered more and more benefits. All the while, policy prices increased exponentially—by double digits even as early as the 1950s.

Although dysfunctional, the insurance company model dominated, Chapin maintains, because multiple parties fought for it based on their myopic predilection that it was better than increased and visible federal intervention. A similar belief, she suggests, guided the design of the 2010 Affordable Care Act, which, like federal programs before it, was built upon the insurance company model. That should be cause for concern, Chapin suggests, given the model's history.