**2. Historical overview**

Some in the U.S. considered the possibility of compulsory health insurance early in the 20th century after noting that 10 European countries had adopted one or another form of it by 1913 [1]. But that idea was controversial, and the emergence of voluntary, private health insurance in this country is especially attributed to a Blue Cross plan for school teachers in Dallas, Texas, in 1929. At that time as the Great Depression took hold, the nation's hospitals were in dire straits with more than one-third of the general hospital beds empty [2].

As the prototype upon which later Blue Cross plans were based, the Baylor plan provided free hospitalization for up to 21 days as well as coverage for operating room, laboratory and anesthesia services. The hospital assumed financial risk for hospital care without any third party and collected pre-payments. Other prepaid health insurance plans were soon to follow. The World War II years saw the start of employer-sponsored health insurance, when employers found it helpful to offer health insurance in order to recruit workers during a wartime economy with a severe labor shortage. By 1950, more than one-half of Americans were covered for the first time [3].

In the last 60-plus years, the private health insurance industry has been transformed from the quasi private-public partnership of its pioneering years to a massive industry on a corporate mission of profit over service. It has followed a conventional theory of insurance based on the concept of "moral hazard," whereby those with insurance are expected to overuse health care services and lead to uncontrolled increases in health care costs. As a result, community rating and guaranteed coverage during earlier years gave way to experience rating as medical underwriting became the new norm. The Blues were under pressure to compromise their earlier service mission, so that one-half of the nation's Blue Cross Blue Shield plans had consolidated and converted into for-profit companies by 2005 [4].

With some 1300 private insurers, the risk pool has fragmented into ever smaller parts as insurers work to avoid adverse selection. Medicare and Medicaid were enacted in 1965 as public plans, but recent decades have seen their increasing privatization that often ends up leaving many enrollees uninsured.

These are some of the many ways that insurers have used to extract more income at the expense of reliable and affordable coverage for enrollees:
