This article uses a unique data set from 1957 to examine the racial gap in health insurance coverage and the extent to which that gap influenced racial differences in health care spending. Results indicate that black households in 1957 were statistically significantly less likely to purchase health insurance than white households, even after controlling for differences in income, years of schooling, age, family size, marital status, and other personal and job-related characteristics. Findings in the article also provide weak support for the hypothesis that a racial gap in health insurance coverage contributed to racial differences in health care spending between blacks and whites; even after controlling for differences in income, education, and other characteristics, racial differences in medical expenditures were smaller for insured than for uninsured families, although the result is not statistically significant.

Health insurance with high deductibles is an important feature of the Bush administration's health savings accounts initiative. A similar type of insurance, known as major medical, was the most common type of health coverage in the United States from the 1950s through the 1970s. This article traces the history of cost sharing in health insurance from its origins in insurers' concerns about “moral hazard” to the heyday of major medical insurance to the temporary comeback of first-dollar coverage during the era of managed care. Proponents of deductibles and co-payments, today and in the past, have argued that they bring down costs by forcing consumers to make more careful health care choices. The history of major medical insurance, however, shows that high-deductible insurance failed to curb medical inflation and also hurt consumers who expected their coverage to protect their incomes from the costs of sickness and injury.

The compulsory medical benefit scheme for white public servants in South Africa grew out of a friendly society founded in 1905. This development diverged from the experience of other members of the British Commonwealth, where universal health insurance schemes developed following the British example. The Civil Servants’ Medical Benefit Association (CSMBA) addressed the needs of white public servants, leaving the non-white communities without any form of government-sponsored medical support, apart from health care provided at government hospitals. The CSMBA was a well-managed medical benefit association, but when it was appointed the compulsory medical benefit association for white public servants, government intervention affected the financial viability of the organization, despite the payment of a state subsidy.

Under the burden of Jim Crow, how did African Americans obtain health care? For nearly 40 years the Afro-American Hospital of Yazoo City, Mississippi, was a leading health care supplier for blacks in the Mississippi Delta. It was founded in 1928 by the Afro-American Sons and Daughters, a black fraternal society, and provided a wide range of medical services. The society, which eventually had 35,000 members, was led by Thomas J. Huddleston, a prosperous black entrepreneur and advocate of Booker T. Washington’s self-help philosophy. The hospital had a low death rate compared to other hospitals that served blacks in the South during the period. It ceased operation in 1966 as a fraternal entity after years of increasingly burdensome regulation, competitive pressure from government and third-party health care alternatives, and the migration of younger dues-paying blacks to the North.

We examine the relationship between age, sickness, and longevity among men who were members of the Hampshire Friendly Society (HFS) in southern England during the late nineteenth and the early twentieth centuries. The HFS insured its members against sickness, death, and old age, keeping detailed records of the claims for sick pay submitted by its members from 1868 onward. From 1892 onward these records included information about the cause of the sickness for which compensation was paid. We can therefore use this information to construct individual “sickness biographies” for men who joined the society during this period. This article uses these sickness histories to address two questions. The first concerns the relationship between the age of the society’s members and the nature of the claims they submitted. We find that both the incidence and the duration of periods of sickness increased with age. Older men experienced longer periods of sickness both because they experienced different types of sickness and because it took them longer to recover from the same illnesses as those suffered by younger men. The second question is whether sickness in early adulthood was associated with increased mortality. We find that repeated bouts of sickness, as revealed by the number of claims made for sick pay, at ages under 50 years were associated with an increased risk of death at ages over 50 years.

Some studies that address the decline of fraternal sickness insurance conclude that fraternal insurers were crowded out of the market by increasing government and commercial competition. This line of reasoning reinforces beliefs that government and commercial insurers were superior to fraternal providers and that voluntary insurance arrangements were deficient for addressing household income risks before the rise of the welfare state. This article shows that this interpretation is problematic. The largest sickness insurer in the United States, the Independent Order of Odd Fellows, dismantled its sick benefit arrangements between the 1860s and the 1920s not because of an inability to compete with the government and commercial insurers that were not in the market until well after 1920 but rather because of declining demand for the insurance within the membership.