By the early 1960s, more than 60 Blue Cross plans reported programs to review claims for the appropriateness of hospital admissions, and more than 50 looked at the length of stay. Some required physicians to certify at admission that hospital care was necessary for cases such as diagnostic and dental admissions, and more than two dozen required physicians to certify the need for continued hospital care after a specified length of stay (Fitzpatrick, 1965; Young, 1965). In a prescient comment, Odin Anderson noted in 1968 that as payers showed increasing interest in medical practice patterns, "the central concern of the medical profession today and in the years ahead might well be 'bureaucracy"' (Anderson, 1968, p. 161).

The various tools used to control costs from the 1930s into the 1960s may have had some impact, but they often were neither rigorously applied nor rigorously evaluated. In general, concerns about controlling costs were still overshadowed by society's desire to expand access and improve health outcomes through the development and implementation of advances in medical care. Government was not a major actor, but neither had marketplace competition emerged as a rallying point for private sector cost containment strategies. Community-oriented programs and cooperative work with health care providers were more prominent themes in this period. Further discussion of private and public efforts to control health care costs, which greatly expanded in the 1970s and 1980s, is deferred until Chapter 6.

As the growth of employment-based health benefits was making such coverage an expected feature of personal life for many Americans, some limitations of voluntary private insurance were simultaneously being identified. The elderly were singled out as a special problem, having greater medical needs but less financial protection than younger individuals still in the work force (Somers and Somers, 1961; Feingold, 1966; Harris, 1969; Marmor, 1973). In 1960, about half of those aged 65 to 74 were thought to have some form of private health insurance—frequently more limited than that available to younger individuals—but only one-third of those over 75 had any protection. Somers and Somers (1961) estimated on the basis of data acknowledged as fragmentary that health insurance met perhaps "one sixth of total medical costs of the insured [but] one fourteenth of the total for all the aged" (p. 445).

The consequences of being uninsured had become more significant as the medical advances associated with World War II and the postwar com-