cover "premiums," but employers have been left with relatively little discretion regarding the details of health benefit programs and with limited involvement in health care cost management.

The exception to this pattern is the United States, where voluntary private action has managed—with some assistance from facilitating national legislation—to extend coverage to the majority of the nonelderly population. Although the concept of workers' compensation had become widely accepted and broadly accommodated in state laws by the second decade of the century and other social insurance concepts were adopted at the national level during the 1930s, insurance for medical care expenses did not follow these precedents. Opposition by important interests outside and inside government to an expanded government role has limited public health insurance programs to the elderly and a segment of the poor. Millions of individuals are not covered by either public or private programs.

The next four chapters of this report describe the current status of employment-based health benefits and discuss developments over the last two decades. Among the key features cited are the

  • extensive involvement by business (primarily large employers) in the design of health plans and efforts to influence the delivery, price, and overall cost of health care;

  • significant responsibilities and administrative complexity for employers, employees, health care providers, and public officials resulting from the expansion and diversity of employers' efforts to manage their health benefit programs;

  • troublesome segmentation of high-and low-cost or high-and low-risk individuals into different insurance pools and growing debate about what constitutes an equitable spreading of risk for medical care expenses;

  • continued escalation in medical care expenditures and uncertainty about the value of this spending despite many efforts to contain medical care prices, limit unnecessary or marginally beneficial use of health care services, and otherwise control costs; and

  • persistent controversy about the merits of public, private, or mixed strategies for achieving a more satisfactory allocation of resources for health care.

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