First, a word about history. We have tried cooperatives before.
During the 1930s and 1940s, the heyday of the cooperative movement in
the United States, the Farm Security Administration encouraged the
development of health cooperatives. At one point, 600,000 mainly
low-income rural Americans belonged to health cooperatives. The
movement failed. The cooperatives were small and undercapitalized.
Physicians opposed the cooperative movement and boycotted cooperatives.
When the FSA removed support in 1947, the movement collapsed. Only the
Group Health Cooperative of Puget Sound survived. Over time, moreover,
even Group Health, though nominally a cooperative, has become
indistinguishable from commercial insurers-it underwrites based on
health status, pays high executive salaries, and accumulates large
surpluses rather than lower its rates.
The Blue Cross/Blue Shield movement, which also began in the 1930s,
shared some of the characteristics of cooperatives. Although the Blue
Cross plans were initiated and long-dominated by the hospitals and the
Blue Shield plans by physicians, they did have a goal of community
service. The plans were established under special state legislation
independent from commercial plans. They were non-profit and, in many
states, exempt from premium taxes. They were exempt from reserve
requirements in some states because they were service-benefit rather
than indemnity plans and because the hospitals and physicians stood
behind the plans. They were exempt from federal income tax until the
1980s. In turn, they initially offered community-rated plans and
offered services to the community, such as health fairs. In some states
their premiums were regulated and they were generally regarded as the
insurer of last resort for the individual market.
Over time, however, the Blues lost their focus on community service
and began to look more and more like their competitors. They abandoned
community rating (which, realistically, they could not maintain when
faced with competition from experience-rated commercial plans) and
began to impose underwriting and cost-sharing requirements
indistinguishable from the private plans. Although providers lost
control of the Blue plans, the plans never took a leadership role in
bargaining aggressively with providers, despite their market dominance
in many states. Many of the largest Blue plans became for-profit, and
those that remain non-profit are largely indistinguishable from
commercial insurers. Although the national Blue Cross/Blue Shield
association offers some coordination services to local plans, it has
not resisted the move of Blue plans away from a community-service
toward a for-profit orientation. Lacking a national focus on public
service, state and regional plans have become indistinguishable from
their commercial competitors.
Blue plans are not the only non-profit insurers that survive. Many
church and fraternal organizations have their own non-profit plans.
Although these plans often try to serve their communities, they usually
have a small presence and little bargaining power in most communities
in which they operate; tend to insure individuals and small groups, the
most costly market; are often the victims of adverse selection; usually
underwrite much like commercial plans; and tend to offer low value,
high cost-sharing policies. They are not a model on which to build
national reform. Mutual insurers are also in theory owned by their
members. They also, however, are indistinguishable from for-profit
insurers in most states.
What can we learn from this history? First, health care cooperatives
are, in fact, an American response to health care reform. Cooperatives
and non-profit insurers were there before for-profit commercial
insurers entered the health insurance business, and we could try to
revive the idea again.
But why would state or locally-run cooperatives be any more successful now than they were when we tried them before?
First, it is hard to imagine how they would get underway.
Capitalization and critical size were problems before and would likely
be problems again. Senator Conrad’s recent draft suggests that members
of the coops would elect their boards, and that the coops would then
obtain state licensure as mutual insurers, meeting state standards for
solvency and reinsurance (with the help of federal seed money). But
there is a chicken and egg problem here. Until the coops had members
they could not have a board. Until they had a board, how would they
meet licensure requirements? The state coops, moreover, would, under
Conrad’s proposal be supervised by a national board, but the national
board would be elected by the state coops. Again, the state coops would
presumably not be able to get underway until the national board
provided policy guidance, but the national board could not get underway
until the state coops were formed to elect it. None of this makes sense.
Second, there is every reason to believe that small, state run coops
would fail like their predecessors did in the 1930s and 1940s. Unless
they reached the critical mass necessary to bargain effectively with
providers, to accumulate reserves, and to compete with national private
insurance plans, they would be doomed to failure. Even if they managed
to succeed here and there, they would contribute nothing to a national
effort to control costs, drive value, and make affordable care
Third, if state-run coops in fact, against all odds, became large,
successful competitors for insurance business, what would keep them
from following the course of the Blue and mutual plans before them?
Without strong Congressional direction and a unifying national
leadership, what could keep them focused on cost control, quality
improvement, transparency, and service rather than simply becoming
indistinguishable from their commercial competitors? How would they
drive the delivery system change we need?
Fourth, how does setting up cooperatives on a state-by-state basis
drive national health care reform? Each state currently can set up
cooperatives if it wishes to, but none have done so. Why would states
suddenly embrace this concept? And what assurance do we have that they
would pursue anything like a common strategy? To approach this issue on
a state-by-state basis is simply to surrender on national health care
reform. A federal fallback plan to be implemented in the future is also
unlikely to work. HIPAA contained a federal fallback plan for states
that failed to implement reforms in the individual market, but it was
poorly implemented and eventually abandoned. To revert to a
state-by-state approach is to surrender on national health care reform.
What Would Make the Cooperative Concept Work?
In fact the cooperative idea in itself is promising. The proposed
cooperatives look much like the social insurance funds of Germany and
of other central European states. Those funds are governed by their
members and do a comparatively good job of keeping health care costs in
check. But they operate in a strong framework of national laws and
under the guidance of national leadership.
The only viable strategy is Senator Conrad’s Option 2–a federal
charter to license and regulate a national non-profit coop, with coop
governance prescribed by Congress. Leadership could initially be
appointed as directed by Congress to represent consumer, labor, and
small business interests, and thereafter be elected by the membership.
The federal government could provide seed funding to assure initial
solvency, but thereafter the coop could be self-supporting. It would be
financed through premiums, and compete on a level playing field with
private insurers (although some account would have to be taken of the
fact that private insurers, no matter what underwriting rules were
imposed, would still dump high-risk insureds into the coop). Some
administrative functions could be delegated to the regional level, much
as Medicare Advantage or drug plans are administered at the regional
level. Regional councils could also be elected by members, who could
have a role in selecting the national board and an influence on
A national cooperative could perhaps compete effectively with
national private insurers. It could perhaps bargain effectively with
providers, including global pharmaceutical firms and national hospital
chains. It is possible that it could drive creative national quality
initiatives and provide national data on health care use. It would not
be government-run insurance, the great fear of the American right. But
it could perhaps provide a national solution for a national problem. It
will not happen on its own, however. It will only work with concerted
and probably long-lasting support from the federal government.
Timothy S. Jost is the Robert L. Willett Family Professor of Law and Ethan Allen Faculty Fellow at the Washington and Lee University School of Law. He is a co-author of a casebook, Health Law, used widely throughout the United States in teaching health law, and of a treatise and hornbook by the same name. He is also the author of Health Care Coverage Determinations: An International Comparative Study; Disentitlement? The Threats Facing our Public Health Care Programs and a Rights-Based Response; and Readings in Comparative Health Law and Bioethics, the second edition of which appeared this spring. This post first appeared at Health Reform Watch.