History is a funny thing. Often, we think we know what happened either as we experience it personally or have trusted sources that give us an account. However, it depends on who is relaying the information, and the prior biases and perspectives. The goal of a good historian is to gather information from multiple sources and figure out what happened and why it played out the way it did. In today's episode we focus on why the US ended up with a third party payer system left to the insurance companies to dictate payment and generally how physicians can practice medicine.

It Begins with Insurance

Dr. Christy Chapin has focused her research on the history of health care which includes insurance and finance. She believes that you must understand how we got to where we are today with insurance (private and public) dictating how medicine is practiced through payment mechanisms. It's easy to look at Medicare and Medicaid and assume that there was always a large influence on health care's practice through insurance reimbursement - but that's not the case. In fact, most doctors assume it was the decade or two before the creation of Medicare in 1965 that insurance really came to be a big player in health care.

Actually it Begins with the AMA

The standard story is that wage controls coming out of WW II left employers with limited ways of attracting top talent since they couldn't adjust employee incomes easily so they resorted to offering benefits like health insurance to entice the ones they wanted. Although that story is a handy explanation, it isn't really borne out by the evidence either in uptake in the frequency of health insurance being offered to employees or its use more broadly in the marketplace. In fact, the creation of health insurance product came from the AMA as they looked to thread the needle and avoid corporate interests taking over medicine (worked out great, huh?) and a federal nationalization.

Unfortunately, the AMA, by squashing all other physician led ways of organizing the delivery of health care, removed all other alternatives to their preferred method - insurance. Initially, the insurance companies agreed to not limit any claims, pay in full whatever charged by the physician, and pay wherever the charges originated (ie, the physician's own lab, etc.). This led to cost over runs and then the endless government fixes including governmental insurance (Medicare/Medicaid) and the resulting changing of the landscape of medicine.

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