The Employer-Based Health
MISTAKE OR CORNERSTONE?
SHERRY A. GLIED
For decades, health policy analysts have voiced their disdain for employer-based health insurance. In 1961, Herman and Anne Somers referred to the system as the “'shotgun' marriage of medical care and industrial relations” (Somers and Somers 1961, 227). Critics routinely belittle job-based coverage as an unfortunate historical accident, the by-product of shortlived wartime wage and price controls that moved compensation toward such benefits (Hyman and Hall 2001). Analysts today see the dismantling of this illogical, inefficient institution as an essential step toward the development of universal, equitable health insurance in the United States (Fuchs 1994).
Yet employer-based coverage is a remarkably durable institution. For nearly seventy years most Americans who hold insurance have obtained it through their jobs. Nor is employer-based health insurance peculiarly American, the inadvertent consequence of U.S. policies. Internationally, employer participation in the health insurance system is more the rule than the exception. And far from impeding the development of universal, equitable coverage, the workplace is the foundation of several successful universal insurance systems.
Today American health policymakers have proposed a range of alternatives that either intentionally seek to dismantle employer-based coverage or are likely to undermine it. The orthodox view of job-based coverage implies that policies that lead to its disappearance would be desirable, or at worst benign. The historical and international persistence of this institution, however, suggests the need for a second appraisal of this venerable institution.
In 2002, 92 percent of all privately insured Americans under sixty-five obtained health coverage through their current or past jobs or through the jobs of family members. The percentage of all Americans under sixty-five who have in-