In this era of intense market-driven competition among health plans, with nonprofit organizations becoming less distinguishable from their for-profit counterparts, it is easy to forget the origins of private health insurance in the United States and the early notions of prepayment that accompanied them. The birth of the Blue Cross organization and its strong commitment to community service are recounted in The Blues. Most readers, when confronted with a historical work sponsored by the very organization whose story is being told, would naturally be skeptical about its truthfulness. Some, therefore, may assume the worst about The Blues, whose authors were commissioned by the national Blue Cross and Blue Shield Association to write a history of its nearly 70 years as a leading health care insurer. They would, however, be mistaken.
The book, by a father-and-son team, is a comprehensive and balanced account of the Blue Cross organization, from its inspired beginnings under Justin Ford Kimball at Baylor's University Hospital in 1929 to its present-day role as a major force in American health care. Assured of noninterference by Blue Cross managers, the authors have crafted an engaging story of a uniquely American 20th-century institution. Their effective use of interviews with top Blue Cross managers and other informed sources results in an unusual look inside the organization -- at its leadership and at the pivotal events and strategic decisions that have shaped it.
The candid observations of the managers paint a realistic (and, at times, unflattering) picture of the Blues and the larger political landscape in which they have operated. The authors dissect the questionable business decisions and missed opportunities (such as the failure to enter the health-maintenance-organization market in the 1970s) with as much intensity as the obvious successes. The result is an informative narrative chronicling the organization's rise, its triumphs and struggles, and its remarkable ability to adapt to changing times and conditions.
In her foreword, Rosemary Stevens describes the failure of the United States to adopt government-sponsored health insurance after the First World War as having set the stage for the creation of private insurance. The book traces the evolution of the Blue Cross organization from a hospital prepayment plan born of pragmatic economic necessity during the Great Depression, through its expansion into prepayment for physicians' services (under Blue Shield plans) and its role as intermediary for the new federal Medicare program in the 1960s, to its struggles in the changing business environment of the 1980s and 1990s as it became a major player in managed care. Throughout its history, the organization has embraced several core principles, including the commitment to "service benefits" (i.e., benefits to individual consumers and to the entire community) rather than indemnity insurance; good working relationships with physicians; the importance of local community involvement; strong standards for local plans; and a belief in the value of private solutions for meeting public needs. The insistence on maintaining nonprofit status -- another early core principle -- gave way in 1994 to the harsh realities of the competitive marketplace.
The Blues deals openly with these issues; its chapter are organized according to decade, allowing readers to focus selectively on specific eras. The book is also filled with quotations from Blue Cross insiders and national health care figures, so that the important health policy issues of the day and the strategic management decisions of organizational leaders are brought to life through their own words and frank appraisals. The aptly named chapter "The 1980s: Swimming with the Sharks" epitomizes the identity crisis in the organization during that period and documents the financial troubles of several plans, such as Empire Blue Cross.
The book is instructive in its analysis of events over the past 70 years, and it offers lessons for those genuinely interested in understanding how the current health care system came to be. Most important, it reminds us that many issues in our system remain unresolved, such as the role of for-profit as compared with nonprofit entities in health care, the philosophical clash between market-based and regulatory strategies and policies, and the continuing search for answers to our problems with cost, quality, and access. Although it offers no definitive answers, The Blues is worth reading for its historical value in providing insight into the nature of the problems that we still face as we enter the 21st century.
Reviewed by Alan B. Cohen, Sc.D.
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