The Natural Family Meets
the Moral Hazard at National Health Care Gulch
By Allan C. Carlson,
This paper was originally delivered as a family policy lecture for the
Family Research Council. It appears here with permission.
care is terrain so craggy and forbidding that only the foolhardy venture to
cross it.” So writes Irwin Unger in his recent book, The Best of
Intentions: The Triumphs and Failures of the Great Society. He analyzes
the effects of the Medicare and Medicaid programs, initiated in 1965, and
concludes that President Lyndon Johnson and colleagues created, at least in
part, “a health Dracula that is now draining the lifeblood of the nation.”
All the same, and despite the monsters
lurking about, I enter that craggy terrain leading down toward National Health
Care Gulch. The facts of national
health care are disturbing. In its
first full year of operation, 1967, Medicare — then embracing Americans ages 65
and over who received Social Security — covered 19 million persons and cost
slightly over $3 billion. Expenses
quickly began to soar, rising an average of 17 percent per year, nearly three
times the general increase in the consumer price index. By 1984, Medicare covered 30 million
persons at a cost of $63 billion, a twenty-fold increase in just 17 years. In 2003, Medicare covered 41 million
persons at a cost of $283 billion.
In that same year, means-tested Medicaid spending totalled another $267
billion: well over half a trillion dollars when added together. More broadly, overall health spending in
the U.S. continues to rise at two to three times the rate of general
inflation. In 2003, the increase
was 7.7 percent, to $1.7 trillion.
As a proportion of the nation’s total output, expenditures for health
reached 15.3 percent. This figure
is, by far, the highest in the developed world; the next closest numbers come
from Germany and Switzerland, at slightly above 11 percent. Some modern nations with universal state
health insurance coverage, such as the United Kingdom, Austria, and Finland,
report figures under 8 percent: about half of the American
Health spending in the U.S. for 2003
reached an average of $5,670 per person.
For a family of five, expenses climbed $1,765 in just one year. According to analyst Paul Ginsburg of
the Center for Studying Health System Change:
insurance premiums are growing faster than what people earn. Government
health care spending is [also] growing faster than federal revenues, crowding
out other priorities.
Moreover, there is the politically
charged issue of Americans not covered by any form of health insurance, private
or public: in 2002, 43.6 million persons and growing, according to the U.S.
These problems are real and vast, and
much debated. Blame for soaring
costs gets cast about widely. Some
indict greedy HMOs. Others point to
overpaid doctors. Still others cite
excessive liability insurance costs for physicians, driven by trial
lawyers. Others blame new and
expensive medical technologies.
And yet, commonly forgotten in this
debate are the relationships of physical health, health care, and health
insurance to healthy marriages and healthy families. Indeed, these are the missing pieces in
the health debate puzzle and the touchstone for real
Moreover, the ongoing debate on health
care and health insurance coincides with special attention this year to the
future of another kind of insurance, old age insurance under Social
Security. The historian in me
whispers that it is time to step back and ask two basic questions: What has been
the historic relationship of insurance, generally, to family life? And, more specifically, how has
government-provided, or social insurance, related to the
Risk-Sharing, Redistribution, and the Moral Hazard
Insurance, broadly considered, is about
the sharing of risk. And it is
important to remember that for most of human history, the extended family was
each individual’s primary insurer.
When tragedy hit, when death came, when sickness struck, one’s relatives
or one’s clan were there to help.
Those without families were in a precarious position, indeed. Even in America today, some groups still
organize their risk-sharing around the extended family or small community:
notably, the Old Order Amish, who avoid most forms of insurance (they are, for
example, legally exempted from Medicare and Social Security). They do this, we should note, because
they believe insurance of the modern sort, public and private, tends to
compromise independence and to weaken family and community
Still, long ago the rise of human trade,
or commerce, began to generate demand for forms of insurance. Traces of insurance contracts for
sea-going vessels can be found in parts of the ancient world, among the
Babylonians, the Phoenicians, and the Greeks. It appears that the ancient Romans
practiced some form of life insurance.
Yet the modern insurance idea developed in the Medieval era, as ties of
clan and family in Europe gave way to ties of mutual interest, such as craft
guilds. Another strand of the
insurance industry developed among religious bodies or ethnic groups organized
as “friendly societies”: that is, societies of friends who knew each other, who
shared common beliefs and values, and who agreed to share certain risks. This approach took strong root among
ethnic and religious groups in the young United States. Both of my grandfathers, for example,
were members of the Skandia Society, which provided insurance and credit for
immigrant Swedes in my hometown of Des Moines, Iowa.
Even in these early forms of
organization, though, the insurance process had three relevant
1) All insurance represents a
displacement of “family centered”
solutions to the problem of risk.
2) All insurance is redistributive. Money is collected from the
participants; some funds are held and some invested; and persons facing certain
specified events will receive payments in return. In true insurance, though, a relatively
large number of the insured will receive less than they paid in, and some may
receive no money back at all (as example, people with health insurance who never
get sick). In order to cover large
losses, this is the only way the system can work.
3) All insurance runs the risk of “the
moral hazard.” In the narrowest
sense, the moral hazard of insurance involves a deliberate act of deception, as
in the arsonist who burns down his newly insured building. The old rule among insurance
underwriters, as phrased by the eminent actuary Albert Mowbray, is that “moral
hazard...is uninsurable on any terms.”
Or as another insurance theorist explains, the vigilant underwriter will
“refuse to accept any application which he feels is contaminated in any way by
the moral hazard.”
The related, “more dangerous” problem is
what insurance analysts sometimes call “the morale hazard.” This form of the moral hazard results
from the indifference created by insurance, as in persons who say: “I have
insurance, so why should I worry?”
Here, the comfort of insurance alters behavior. In some cases, people become more
careless, sloppier. In other cases,
they make lifestyle decisions that increase their risks. They may take up skydiving as a hobby,
because they have life insurance.
Or they may decide to indulge in risky sexual behaviors, because they
have health insurance. Notably,
eminent insurance theorists agree that “the moral hazard is perhaps more serious
in health insurance than in any other branch of insurance.” As we shall see, this is true in more
ways than one.
Social Insurance and
insurance can be succinctly defined as “the attempt of government to apply the
principle of insurance to the prevention or alleviation of poverty.” A
broader definition is provided by the actuary Ralph
insurance is any form of insurance in which the government goes beyond the
regulation of [insurance] practices and the dissemination of information.
It may do so by compelling insurance, by shifting its cost, by subsidy, or by
becoming itself an insurer.
In modern societies, the contingencies
commonly covered include sickness, maternity, accident, unemployment,
invalidity, age, and premature death.
Most historians argue that compulsory insurance of this sort was a
logical and inevitable result of industrial development (although the Amish, who
today compete quite well in industries such as furniture making, stand as living
denials of the term “inevitable”).
Importantly, “sickness insurance” was the first form of social insurance
to emerge in the modern Western world.
In 1883, the Reichstag of the old German Empire, at the prompting of
Chancellor Otto von Bismarck, approved a compulsory health insurance plan for
German workers. By the 1930’s, most
European nations had followed suit.
A common aspect of all of these early
social insurance projects was their assumption of a distinctive family
system. Except in the Communist
Soviet Union, European nations built their programs on the model of a
breadwinning husband and father, a homemaking wife and mother, and a home
focused on rearing children.
Working women were rarely eligible for coverage through their outside
work; rather, women received their benefits mainly through their roles as wives
and mothers. If a husband died, a
woman and her children normally received continued health care, a death benefit,
survivor’s insurance, and/or a mother’s pension. So it might be said that these early
systems were pro-family, albeit — by contemporary standards — in a fairly rigid
The story in America differed somewhat
from Europe. Prior to the Great
Depression of the 1930’s, the federal government had little experience in social
insurance. The one exception was
the Sheppard-Towner Act of 1921.
Passed over the fierce opposition of the American Medical Association
(AMA), Sheppard-Towner provided funds to states for prenatal, maternal, and
infant health education and care.
It was the first federal entitlement; there was no means test. Visiting nurses for pregnant women were
a common Sheppard-Towner project, and there is some evidence that the program
did directly reduce maternal and infant death rates. Still, despite this success — or some
would say because of
it — the AMA succeeded in repealing Sheppard-Towner in
Among the states, there were tentative
experiments in social insurance programs.
Mother’s pensions for widows were the most popular. Several states adopted small workmen’s
compensation programs. Yet the
American commitment to individual and family responsibility stymied most other
initiatives. For example, during
the early 1920’s, several states studied sickness insurance. But the lack of any sense of crisis and
powerful opposition by the AMA to “socialized medicine” cut off these
Economic Crisis and
Then came the economic collapse of the
early 1930’s, the election of Franklin D. Roosevelt as President in 1932, and
the initiative known as the New Deal.
In June 1934, he created the Committee on Economic Security to study
social insurance questions. The
Committee’s report led directly to passage of the Social Security Act of
1935. This measure resurrected the
Sheppard-Towner program of prenatal and infant-care education and federalized
mother’s pensions as the Aid to Dependent Children program. The measure also created old age
insurance funded by “contributions” into individual accounts, together with
death and unemployment benefits for covered workers.
As in Europe, the new American Social
Security system assumed a breadwinner/homemaker/child-centered home as its
model. As one of the architects of
Social Security, Abraham Epstein, explained in his 1933 book, Insecurity: A
Challenge for America:
It must be
remembered that the American standard assumes a normal family of man, wife, and
two or three children, with the father fully able to provide for them out of his
own income. This standard presupposes no supplementary earnings from
either the wife or young children.
The Social Security Amendment of 1939
strengthened this orientation by adding survivor’s insurance for male workers
and a homemaker’s pension for their wives.
Unlike in Europe,
though, neither the 1935 or 1939 Acts included sickness insurance. As the
Committee on Economic Security had ruefully noted, any such system of national
health care would need to rest on “sound relations between the insured
population and the professional practitioners”; that is, on the happy
participation of the doctors. And the AMA remained firmly opposed.
Still, the report laid out principles for a future national system. It
should: provide “adequate health and medical services to the insured
population and their families”; “exclude commercial...agents between the insured
population and the professional agencies which serve them”; and provide “cash
payments in partial replacement of wage-loss due to sickness and for maternity
cases and...health and medical services,” benefits that could be provided by
additional payroll taxes of about six percent.
The idea of compulsory national health
insurance covering all workers and their dependents was reborn during the
closing years of World War II. In
November 1945, Harry Truman submitted to Congress a Presidential message on
health care which called for such a plan.
Opposition by the AMA prevailed again. Instead, a modest wartime expedient
began to shape an alternate system.
The Internal Revenue Service had ruled in 1942 that employer-provided
health insurance would be exempt from taxation. This stimulated growth of the
now dominant American alternative, where health coverage offered by private
insurers is closely tied to employment.
Meanwhile, advocates for a unitary
national system turned to incremental steps. In 1956, Congress added disability
coverage to Social Security. And in
1960, the Kerr-Mills bill became law, providing medical aid to the aged poor on
a means tested basis.
The big step came in 1965. Lyndon Johnson’s overwhelming victory
over Barry Goldwater the prior year, and huge Democratic majorities in both the
House and Senate, set the stage for creation of the Medicare and Medicaid
programs. Since the late 1930’s,
some advocates of social insurance had suggested turning next toward universal
health coverage for the aged. The
political advantages of giving aid and support to this huge voting block were
obvious. In retrospect, however, it
is clear that arguments used to sell these measures to the public were, at best,
flawed; at worst, deliberate deceptions:
1) To begin with, advocates portrayed
elderly Americans as an unusually impoverished group, a sympathetic body
desperately needing tax-supported medical insurance. Income statistics provided by the U.S.
Department of Health, Education & Welfare showed the elderly having, on
average, lower incomes than other adult age categories. Yet these statistics totally ignored
asset ownership, including private annuities, insurance contracts, property,
private pensions, and savings, where the elderly enjoyed an overwhelming
advantage. They also failed to note
that most of the elderly were, in fact, retired, meaning that their “incomes”
would be relatively low.
2) Advocates for Medicare and Medicaid
also spread misinformation about the coverage to be provided. The image held up was that of the
responsible elderly being financially ruined by a catastrophic illness. In fact, the Medicare plan would only
provide 60 days of hospital care; Medicaid would kick in only after the patient
ruined. In short, neither measure
provided catastrophic coverage. As
one honest Democrat of the time, Russell Long of Louisiana, asked during a
“Well, in arguing for your plan you say
lets not strip poor old grandma of the last dress she has and of her home and
what little resources she has and [then] you bring us a plan that does exactly
that unless she gets well in 60 days.”
3) Moreover, advocates provided
wildly misleading future cost estimates. In 1965, the Johnson
Administration — even using a generous inflation estimate — calculated that
Medicare would cost only $12 billion in 1990. The actual cost turned out
to be $110 billion, nearly ten times the estimate. The price tag for
taxpayers was also carefully camouflaged in the bill, with payroll tax increases
preplanned through 1987.
4) In addition, the program was sold as a
measure of social and economic justice.
In practice, though, the new Medicare tax was regressive, falling most
heavily on the working poor and the lower middle class. Indeed, the program actually saw the
working poor subsidizing the medical care of the retired rich. California Republican James Utt
fumed over the false assumption “that everyone over 65 is a pauper and everyone
under 65 is rolling in wealth,” but to no avail.
5) Finally, advocates
advanced the measure as pro-family.
It would relieve adult children of the responsibility and burden of
caring for their elderly parents, they said, so allowing these younger adults to
invest more resources in their own children. This surely did not happen. In fact, 1965 actually marked the end of
the Baby Boom and the beginning of a massive retreat from children. In practice, the advent of Medicare and
Medicaid merely represented another step in socializing direct intergenerational
duties and bonds. Where families
once took care of their own, that task would now be further transferred to the
state. [As an aside, I note that a
much stronger “pro-family” — or at least “pro-child” — case for incremental social insurance could
have been made if proponents had turned to universal coverage for prenatal
services, maternity, and infant care.
Society holds a clear interest in healthy mothers and healthy
babies. And unlike elder care,
maternal and infant medical services are truly “preventative,” where you can
show a clear return on timely intervention. However, the elderly proved to be a much
more attractive political constituency than were babies.]
Today, the American health care system is
a sprawling, joint public-private venture.
Projections for 2005 show total health expenditures of
$1,907,000,000,000, an astonishing number.
Of this, $858 billion will be covered by public insurance, $702 billion
will be covered by private insurance, $262 billion out-of-pocket, and $98
billion by other private sources.
This system combines the provision of excellent care to many alongside
remarkable inefficiencies and massive gaps in coverage, all fueled by the
infusion of an ever higher percentage of our national
It is impossible for me — perhaps for
anyone — to outline new policy measures that could set all things right. The Gulch is too deep. Relative to the family, though, I want
to highlight two examples of “the moral hazard” that have grown within this
system and offer responses. The
first expression of “the moral hazard” here is the lifestyle subsidy which the
existing American system now gives to non-family living.
One of the oldest and strongest findings
of social science and public health is the relationship between marriage and
raising children and good health.
As early as the 1860’s, William Farr, the superintendent of England’s
Statistical Department, had identified the marriage-health connection. Examining data from France, he found the
death rate for unmarried men, ages 20 to 30, to be 75 percent higher than that
for married men of the same age; this also remained true for men in their
forties. Among women, childbearing
in the era before antibiotics remained somewhat risky and raised the mortality
rate for the young and married.
However, after age 40, unmarried women also exhibited death rates 50
percent above those of the married.
As Farr concluded:
This is the general result:
Marriage is a healthy estate. The single individual is more likely to be
wrecked on his voyage than the lives joined together in matrimony.
More recent inquiries have confirmed the
health-giving effects of family living.
Looking specifically at the United States of the 1980’s, Debra Umberson
reported in the Journal of Health and Social Behavior that:
…the married have the lowest rates
of negative health behaviors, and the divorced, the highest rates. Marital
status is somewhat more important to health behaviors than is parenting status.
Parenting status, however, also has a deterrent effect on health compromising
behaviors. This deterrent value depends more on the presence of children
in the home than simply having had children.
Some have suggested that the health
giving effect of marriage primarily benefits men. As the feminist author, Jessie Bernard,
once put it: “men need marriage more than women do.” However, when sociologists Catherine
Riessman and Naomi Gerstel tested this thesis in 1985, they found surprising
[O]n four of the five [health]
indicators, separation has a more negative effect on women than it does on men.
More specifically, separated women are more likely than separated men, relative
to their respective cohort, to restrict activities due to illness, to limit
activity due to chronic disease, to report acute conditions and to visit
physicians. Moreover, divorce also has a more negative effect on women
than men on most of these same health indicators.
Indeed, the evidence on the health-giving
effects of traditional family living continues to grow. From The Journal of Family
The consistency of the health
benefit of marriage, across all domains of health is remarkable.... Divorces
appear to have the worst overall health profile.
From Social Science and
Having children in the home is
definitely associated with more favorable outcomes in terms of perceived health,
physically disabling conditions and health-related behavior for women with a
husband/co-habitant [that is, a husband in the home].
From The Journal of Health and Social
Women’s risk of dying
decreased as spousal income increased but the opposite was true for men (both
[relationships] are statistically significant)....[I]ncreasing spousal income is
an asset for women but a liability for men.
From the Archives of Pediatric and
Exclusive breastfeeding for 4 or
more months appears to diminish the risk of respiratory hospitalization in
infancy to one third or less the risk observed for formula-fed infants.
From The British Medical
Children attending day care
centers have a 1.5-3.0 times higher risk of gastrointestinal and respiratory
tract infections than children cared for at home or in small family care groups.
And from the journal Public
This decrease in [hospital] bed
usage among the married occurred despite their continuing, albeit declining,
majority status within the general population.... The positive relationship
between marriage and health has increased steadily since the 1970’s onwards,
despite the challenges to marriage in modern society.
This all sounds like good news. But, as the last citation hints, there
is a flipside to the story: the proportion of persons living in traditional
married couple homes with children is declining. Indeed, consider the recent changes in
American family life outlined in chart A.
As marriage, long-term breastfeeding, and
maternal child care at home all are associated with good health, these turns
toward non-marriage, divorce, cohabitation, childlessness, working mothers, and
small children in day care all have the opposite effect: poorer health and
higher medical costs. Indeed, these
negative turns are surely caused, at least in part, by the moral hazard of
insurance coverage. Precise
calculations here are not yet available, but I would reasonably estimate that
about 25 percent of today’s high health costs are the direct result of these
changes in household structure and behavior.
In practice, this
also means that remaining intact natural families are providing a lifestyle
subsidy for persons who now live outside traditional family bonds. This
lifestyle subsidy is paid directly through social insurance measures such as
Medicare and Medicaid. It is also paid through private insurance,
particularly where health insurance providers are not allowed to discriminate on
the basis of marital status, or where they are forced by law to cover unmarried
cohabitors and homosexual partners.
Rise of the
The second form of “the moral hazard”
spawned by our health care system is part of a larger pattern: the change in
normative assumptions guiding social insurance. As noted before, the welfare states that
developed throughout the Western world between 1885 and 1965 openly favored a
distinct family model: a breadwinning father; a homemaking mother; and children
receiving full-time maternal care.
Income transfer policies, from Sweden to the United States to Australia,
uniformly taxed income and wealth from those over age 40 and gave most of it to
young married adults with children.
In the United States, this was achieved — sometimes indirectly — through
large tax exemptions for children and the practice of income splitting in the
tax code; through generous housing subsidies through VA and FHA programs; and
through a payroll tax that remained small.
This all changed, though, starting —
again — in 1965. Not only were
Medicare and Medicaid initiated that year; the same bill also provided for an
across-the-board 7 percent increase in Social Security retirement benefits and a
big jump in the payroll tax. Other
increases in pension benefits followed, including a generous indexing
formula. As a result, by the 1970’s
the young-family welfare state was rapidly giving way to the elder-care
state. Meanwhile, the Aid to
Families with Dependent Children program and related measures grew rapidly,
funneling billions of dollars more to unmarried women with children. Where the redistributive effects of the
American social insurance system of, say, 1960 had favored the male breadwinner,
female homemaker, child rich family, the American system of income
redistribution in, say, 1985 strongly favored the elderly and single
mothers. Married couple families
with children were now the clear losers.
Can we gauge the size of this
change? Looking at the same
phenomenon in New Zealand, sociologist David Thomson calculated that persons
born in 1930 will have contributed about 17 years of average pay in taxes over
their lifetime and will have received back 35 years worth in benefits. However, those born in 1955 will pay
27.6 years of average pay in taxes, while receiving at best 27.4 years in
benefits back. No net gain; perhaps
a small loss. Meanwhile, those born
after 1960 will post a net loss of ten years pay. When compared to those born in 1930,
those born after 1960 will have to work up to 28 more years than the earlier
couple just to enjoy the same relative standard of living. Thomson even calls that earlier cohort
“the selfish generation.”
Australian analyst Alan Tapper suggests
that in light of this shift of the welfare state, certain parallel trends in
family life should cause no surprise.
He points to:
...delayed marriage, less
marriage, reduced fertility, an unprecedented divorce rate, and the trends
towards the two-earner family, all tendencies which came into prominence in the
period after 1970, when the financial forces [of the welfare state] were arrayed
against the young.
While calculations of this complexity
have yet to be done for America, some preliminary work suggests the same
story. Laurence Kotlikoff and
Jagadeesh Gokhale, writing in 1994 for The Public Interest, report that “today’s children may have
to hand upwards of 40 percent of their lifetime income over to the government
while their grandparents will end up paying just over a quarter of their
lifetime income.” For most
Americans in their 20’s and 30’s, moreover, the heaviest tax burden that they
now face is the payroll tax, taking 15.3 percent of their income from the first
dollar earned: part for old age, survivors, and disability insurance; part for
Medicare. Total federal dollars
flowing directly to the elderly totalled about $900 billion in 2001; direct
federal benefits specially flowing to young, intact families with children were
In short, the moral hazard distorting our
health insurance system is now evidenced in both the subsidy and encouragement
provided to unhealthy, non-family lifestyles and choices and in the mounting tax
burden imposed on young adults, the very ones who must form families if our
society is to have a future. How
might we respond?
private health insurance, the need — in Bryce Christensen’s words — is “to let
actuaries be actuaries.” Measures such as the Americans with Disabilities
Act, the Health Insurance Portability and Accountability Act, and so called
“community rating” schemes are — in Richard Epstein’s words — “making
information a near-forbidden commodity” for health insurance companies.
With “elements relevant to the accurate pricing of risk...excluded from view,”
including age, sex, marital status, and sexual preference, everyone becomes
“more likely to engage in riskier activities.”
In a properly
ordered society, those men and women who marry, bear children, and rear them at
home should reap the benefit of making such naturally healthy choices. By
committing to marriage and home, and on the basis of sound business principles,
they deserve preferential treatment in health insurance, meaning significantly
lower insurance rates. Those who remain single, divorce, cohabit, or
engage in non-marital sex should pay higher rates. To cries of
“Discrimination!,” the proper answer is “No lifestyle subsidy!”
Turning to social insurance, perhaps
American families need to acknowledge a hard lesson. Back in the 1930’s, they surrendered
both substantial autonomy to the state and their natural advantage in
maintaining good health in exchange for a Social Security system that did show
“pro-family” elements and that did, for one generation, deliver substantial
benefits their way. Yet, as
outlined above, the scheme turned sour during the late 1960’s. In retrospect, it appears to have been a
fool’s bargain. By the 1980’s,
young families had become the net losers in this state income redistribution
scheme: not only in America, but in all Western countries. Not much has changed since, nor is it
likely to, given current political realities (that is, the elderly vote; infants
and children do not). The hard
lesson here is that “communitarian” policies such as social insurance, even when
crafted with the best of intentions, can only work in small communities, where
people can know and watch over their neighbors and so prevent “the moral hazard”
from emerging. Real family autonomy
and community strength normally exist in inverse relation to government size and
Regarding health care, the corollary is
to begin taking prudent steps to dismantle the Medicare-Medicaid regime, so that
the real benefits and advantages of life within the natural family can come back
into play. For example, this family
perspective strengthens the case for the favorable tax treatment and expansion
of private medical accounts.
Relative to Medicare, the goal should be to reorient the program over
time away from universal coverage toward higher co-pays, means-testing, and an
emphasis on catastrophic care.
Incentives such as credits against payroll taxes should be provided to
families that care for ailing elderly relatives in their homes. Medicaid should refocus on prenatal,
maternal, and infant care, the one clear place where “preventive medicine”
produces powerful results and where the moral hazard seems
There are dozens of other incremental
steps that might be taken. Rather
than a tedious review, let me recommend instead one simple, general
With a possible exception for prenatal,
maternal, and infant health measures, support all initiatives that deconstruct
social insurance health coverage and that encourage market forces based on sound
and thorough actuarial principles, including the consideration of household and
Under this test, I believe, the natural
family can only gain.
Irwin Unger, The Best of Intentions: The Triumphs and Failures of the
Great Society Under Kennedy, Johnson, and Nixon (New York: Doubleday, 1999):
In Robert Pear, “Nation’s Health Spending Slows, but It Still Hits a
Record,” The New York Times (January 11, 2005):
C.F. Trenberry, The Origin and Early History of
Insurance. Including the Contract of
Bottomry (London: P.S.
King and Son, 1926): 246-60.
Albert H. Mowbray, Insurance: Its Theory and Practice in the United
States (New York and
London: McGraw-Hill, 1946): 19.
John D. Long, Ethics, Morality and Insurance: A Long-Range
IN: Bureau of Business Research, Graduate School of Business, Indiana
University, 1971): 41.
Robert I. Mehr and Emerson Cammack, Principles of
Insurance (Homewood, IL:
Richard D. Irwin, 1961): 720.
7 Proceedings of the Casualty Actuarial Society, Vol. XXIV (1937); in
Mowbray, Insurance, p. 548.
8 Presidential Address, Proceedings of the Casualty Actuarial Society,
Vol. XXIX (1942); in Mowbray, Insurance, p. 548.
9 Molly Ladd-Taylor, “My Work Came Out of Agony and Grief: Mothers and the
Making of the Sheppard-Towner Act,” in Seth Koven and Sonya Michel, eds.,
Mothers of a New World: Maternalist Politics and the Origins of the Welfare
State (New York: Routledge, 1993): 329-37.
10 Abraham Epstein, Insecurity: A Challenge to America (New York: Harrison Smith
and Robert Haas, 1933): 101-02.
11 Report to the President of the Committee on Economic Security (Washington,
DC: U.S. Government Printing Office, 1935): 41-43.
12 Quoted in Charlotte Twight, “Medicare’s Origin: The Economics and Politics of
Dependency,” The Cato Journal 16(3); at http:www.cato.org/pubs/journal/cj16n3-3.html
(1/17/2005): p. 8.
13 Robert B. Helms, “The Origins of Medicare,” Washington, DC: AEI
Online, 1 March 1999; at
14 Quoted in Twight, “Medicare’s Origin,” p.
15 William Farr, Vital Statistics, ed. Noel Humphreys (London: Offices of
the Sanitary Institute, 1885): Report #10.
16 Debra Umberson, “Family Status and Health Behaviors: Social Control as a
Dimension of Social Integration, “Journal of Health and Social
Behavior 28 (1987):
17 Jessie Bernard, The Future of Marriage (New York: Bantam, 1979):
18 Catherine Kohler Riessman and Naomi Gerstel, “Marital Dissolution and
Health: Do Males or Females Have Greater Risk?” Social Science and
Medicine 20 (1985):
19 Amy Mehraban Pienta, Mark D. Hayward, and Kristi Rahrig Jenkins, “Health
Consequences of Marriage for the Retirement Years,” Journal of Family
Issues 21 (July 2000):
20 Myriam Khlat, Catherine Serment, and Annick LePape, “Women’s Health in
Relation with Their Family and Work Roles: France in the Early 1990’s,” Social Science and
Medicine 50 (2000):
21 Peggy McDonough et al, “Gender and the Socioeconomic Gradient
in Mortality,” Journal of Health and Social Behavior 40 (1999): 17-31.
22 Virginia R. Galton Bachrach, Eleanor Schwartz, and Lela Rose Bachrach,
“Breastfeeding and the Risk of Hospitalization for Respiratory Disease in
Infancy,” Archives of Pediatric and Adolescent Medicine 157 (2003):
23 Katja Hatakka et al, “Effects of Long-Term Consumption of
Probiotic Milk on Infections in Children Attending Day Care Centres: Double
Blind, Randomized Trial,” British Medical Journal 322 (2 June 2001):
24 P.M. Prior and B.C. Hayes, “Marital Status and Bed Occupancy in Health
and Social Care Facilities in the United Kingdom,” Public
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25 See: Bryce Christensen, “A Calculated Risk: Making Health Insurance an
Ally of the Family,” The Family in America 12 (Dec. 1998):
26 David Thomson, Selfish Generation?: How Welfare States Grow
Old (Cambridge, England:
The White House Press, 1996): 154-91.
27 Alan Tapper, “Do Families Fare Well Under the Welfare State?” The
Family in America 11
(July 1997): 4.
28 Laurence J. Kotlikoff and Jagadeesh Gokhale, “Passing the Generational
Buck,” The Public Interest (Winter 1994):
29 See: Richard Epstein, Mortal Peril: Our Inalienable Right to Health
Care? (New York: Addison
Wesley, 1997): 144-45.
30 See: Christensen, “A Calculated Risk,” pp.