death or total disability and gradually expanded to cover various kinds of accidents and illnesses. These early products employed the standard actuarial principles and techniques that had been developing in the fields of life, fire, and marine insurance.

Efforts to extend commercial accident-and-sickness insurance, as it was often called, to expenses for medical care were intermittent and limited during the latter part of the nineteenth century and first third of the twentieth century (Faulkner, 1940, 1960; Somers and Somers, 1961; Starr, 1982). Life insurers made some efforts to add medical expense benefits to their newly developing group life insurance programs aimed at employers, but these attempts were sporadic. In general, insurers considered medical expense benefits to be actually dubious and a "frill" (Faulkner, 1940; Somers and Somers, 1961).⁵ Overall, as a vehicle for and influence on health insurance, commercial insurers played a relatively limited role in most European countries. They became major actors in the United States largely after World War II, once community-based organizations, hospitals, physician groups, and government policies provided evidence that private medical expense coverage was feasible.

It was on the foundation of the early but limited initiatives of union, mutual aid, and other groups that most European governments created their policies of compulsory, subsidized medical expense protection beginning in the late nineteenth century (Anderson, 1972; Starr, 1982; Glaser, 1991). This foundation remains visible in some countries, for example, in the sickness funds of Germany. In yet other countries, it has largely been replaced by alternative structures, for example, the National Health Service in Britain.

Generally, the building of publicly supported arrangements for medical expense protection was embedded in the broader development of social insurance and other policies to protect workers, their families, and others against various harms, in particular, the loss of earning ability due to old age, disability, or workplace injuries (Flora and Heidenheimer, 1981; Weir et al., 1988).⁶ As described in Chapter 1, social insurance for medical expenses shares common features with other social insurance programs. It is universal or nearly universal; coverage is virtually automatic or compulsory for most of the population; common basic benefits are available with-