This issue of the Milbank Quarterly begins with Ellen O’Brien’s article, “Employers’ Benefits from Workers’ Health Insurance.” Health insurance as an employee benefit is a central feature of the American health care system and policy. This long established pattern is seen variously as either a foundation for or barrier to needed changes in the American health system. Its persistence is important to understand, and O’Brien examines a largely overlooked economic explanation.

Economists have generally explained the employment-based system in terms of worker demand. That is, in a competitive labor market, employers provide health insurance because workers want it and willingly pay for it in the form of wages reduced by the amount of the cost of the insurance. But O’Brien suggests that to the contrary, health insurance may be worth more to employees than it costs employers. More important, she lays out an argument for a “business case” for employer-provided health insurance based on improved productivity, lower labor costs, and better overall firm performance. She concludes, “To the extent that employers view health benefits as investments in the workforce, the likelihood that they would drop employment-based plans in response to individual tax credits, or shift to defined contributions, may have been overstated.”

David Rosner and Gerald Markowitz offer a historical perspective on the same topic in their article, “The Struggle over Employee Benefits: The Role of Labor in Influencing Modern Health Policy.” This fresh assessment of labor’s role in health policy over the past century is one of the papers commissioned for the centenary of the Milbank Memorial Fund (Rosenberg 2002; Markel and Stern 2002). Rosner and Markowitz argue that labor’s influence on public policy has been underappreciated, and they point out that public and private social welfare and health insurance systems, in fact, grew out of pressures exerted by organized and unorganized labor movements. Building on their earlier work (Rosner and Markowitz 1987, 1991), they elucidate labor’s historical role in an array of policy arenas, including workplace safety, occupational health, workers’ compensation, and private and public insurance. They also trace labor’s declining influence on these matters in recent decades.

The next article presents an empirical study by Scott Bilder and David Mechanic of the two national programs that provide income support for disabled people—the Social Security Disability Insurance (SSDI) and the Supplemental Security Income (SSI) programs. In “Navigating the Disability Process: Persons with Mental Disorders Applying for and Receiving Disability Benefits,” Bilder and Mechanic analyze data from the National Health Information Survey on Disability to identify factors that predict whether persons with self-reported mental disorders apply for SSDI or SSI and whether they receive benefits from these programs. More than one-fourth of SSDI recipients and more than one-third of SSI recipients are eligible because of mental disorder, and between 1991 and 1999, the number of such recipients increased by 75 percent and 100 percent, respectively. Even so, there is concern that the seriously mentally ill may have difficulty negotiating the complex process of establishing eligibility for these programs. Bilder and Mechanic found that the persons with mental disorders who are most likely to apply for these programs are the ones with the greatest disabilities and the fewest financial resources, a pattern that also appeared among those applicants who receive benefits. These findings provide some assurance that the system is working as intended. But at the same time, Bilder and Mechanic report a subset of people with serious mental illness who are unable to work and have not applied for benefits. They suggest that this population should be a target of programs that provide information and support in the application process.

In “Chiropractic in the United States: Trends and Issues,” Richard A. Cooper and Heather J. McKee examine the status and prospects of the best-established form of what has come to be known as “complementary and alternative medicine” (CAM). Called “unconventional medicine” a decade ago in a major review estimating that some 425 million visits were made annually to alternative therapy providers (Eisenberg et al. 1993), CAM is now the object of its own research center in the National Institutes of Health. Cooper and McKee note chiropractic’s movement from the margin to the mainstream of health care, as signified by, for example, coverage by third-party payers.

Notwithstanding popularity with patients, legitimacy in today’s mainstream health care increasingly requires evidence of effectiveness. Although chiropractic subscribes to a distinctive theory of disease, its move toward the mainstream has widened the schism within the profession between the “straights,” who adhere to spinal manipulation as the treatment for a variety of disorders, and the more numerous “mixers,” who recognize a broader range of causes of disorders and use various forms of therapy, including spinal manipulation. Cooper and McKee note that the mixers are generally open to examinations of outcomes. This issue of effectiveness raises such questions as whether there is a distinctively chiropractic spinal manipulation therapy that should be compared with manipulation therapy administered by other types of practitioners (physicians, massage therapists) or whether spinal manipulation therapy should be tested against other approaches to treating patients with low back or neck pain. Cooper and McKee provide a useful summary of the current state of the evidence. The paradox of “alternative” medicine seeking to become more scientific makes the current story of chiropractic not only an interesting topic for health policy but also a fascinating study in the sociology of occupations.

This issue concludes with five commentaries on the article by Sherry Glied, Dahlia Remler, and Joshua Graff Zivin in the December issue of the Quarterly. In “Inside the Sausage Factory: Improving Estimates of the Effects of Health Insurance Expansion Proposals,” Glied, Remler, and Graff Zivin explained how economists predict the effects of proposals to expand access to health insurance and why the estimates generated by various individuals and organizations inside and outside government can (and often do) differ substantially for reasons not apparent to users. To make the modeling process more transparent, the authors proposed that modelers adopt some conventions—using what they term a reference case—that would enable users to see and assess the decisions and assumptions that translate into differences among modelers in their predictions of cost and coverage. Glied, Remler, and Graff Zivin expressed the hope that modelers would voluntarily adopt conventions of transparency, but they suggested that users of budget estimates demand standardization to make it easier to compare them.

The commentaries were written by two veteran producers of budget estimates, John Sheils, vice president of the Lewin Group, and Dan Crippen, director of the Congressional Budget Office; Mark Pauly, professor of economics at the University of Pennsylvania and a leading expert on the economics of health insurance; and two users of budget estimates from the U.S. Senate, David Nexon, minority staff director of the Committee on Health, Education, Labor, and Pensions, and Linda Fishman, health policy director of the Finance Committee. It is perhaps not surprising that although the producers of estimates see disadvantages in the proposed reforms, the users are enthusiastic about the prospect of more transparency in budget estimates. The commentaries finish with a brief response from Glied, Remler, and Graff Zivin.

Bradford H. Gray
Editor, The Milbank Quarterly


Eisenberg, D.M., R.C. Kessler, C. Foster, F.E. Norlock, D.R. Calkins, and T.L. Delbanco. 1993. Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use. New England Journal of Medicine 328(4):246–52.

Markel, H., and A.M. Stern. 2002. The Foreignness of Germs: The Persistent Association of Immigrants and Disease in American Society.Milbank Quarterly 80(4):757–88.

Rosenberg, C.E. 2002. The Tyranny of Diagnosis: Specific Entities and Individual Experience. Milbank Quarterly 80(2):237–60.

Rosner, D., and G. Markowitz, eds. 1987. Dying for Work: Workers’ Safety and Health in 20th Century America. Bloomington: Indiana University Press.

Rosner, D., and G. Markowitz. 1991. Deadly Dust: Silicosis and the Politics of Occupational Disease in Twentieth Century America. Princeton, N.J.: Princeton University Press.

Author(s): Bradford H. Gray

Read on Wiley Online Library

Read on JSTOR

Volume 81, Issue 1 (pages 1–4)
DOI: 10.1111/1468-0009.00183-i2
Published in 2003