In the 50 years since its founding, Group Health Cooperative of Puget Sound evolved from a tiny bank of outcast physicians and consumer zealots to the largest consumer-governed health care organization in the United States. The founders pioneered the concept of prepaid managed care that now, for better or worse, prevails throughout the land. Seattle writer Walt Crowley, with access to a wealth of written records, meeting minutes, and oral histories, covers each of those 50 years in painstaking fashion in To Serve the Greatest Number, written under Group Health auspices (read paid-for), and published by University of Washington Press. How far Group Health has come is illustrated by a description of the private party in the Columbia Tower Club in 1993 celebrating the "engagement" of Group Health and Virginia Mason. Had the Tower Club existed in 1947, the renegade founders of Group Health would not have been invited, they would not have attended. They were a rough and ready lot, more comfortable with a lunch bucket than with a cocktail glass.

I have a special perspective on those early days, when I was a youngster. I recall meetings in our living room, where articulate advocates tried to persuade my parents and other Progressives to get in on the ground floor of this revolutionary movement. My parents joined, more for ideological than pragmatic reasons and soon faced a dilemma. I came down with a generalized skin infection, which, in an era when antibiotics were not yet readily available, was serious business. The concept of consumer-owned medical care was attractive, but my parents had no idea whether the physicians were competent. The Group Health physicians were vilified by their colleagues and were denied membership in the King County Medical Society. Fortunately my parents took the plunge and took me to Group Health's first pediatrician, William A. (Sandy) MacColl. He not only capably managed my illness, but through his qualities as a model clinician, humanist, and social activist inspired me to seek a career in medicine.

I love the descriptions of MacColl in Crowley's book. In 1952, when conflicts between the Coop Board and the medical staff threatened to scuttle the fledgling organization, MacColl was drafted to serve as Executive Director. He hated the job and could not wait to return to his pediatric practice. When he did in 1955, it was at the small Northgate satellite clinic. As the Group Health grew, his influence waned. Though revered as a founding icon, MacColl's idealistic views were considered anachronistic for a large organization tiptoeing along the financial bottom line.

Crowley does a fine job describing the constant struggle to meld the socialist views of the founders with financial realities. For example, they felt that all medical specialists should be paid the same; the marketplace quickly dictated otherwise. Group Health's whole history has been one of compromise in order to stay alive. By quoting from the minutes of the often-tumultuous annual meetings, the author nicely reflects the emotional debates over basic policy issues such as requiring copayments for drugs, coverage of subscribers for preexisting conditions, the utility of annual physical examinations, and whether to provide coverage for heart transplants. Not surprisingly, abortion was the issue generating the most heat. A small but active group of members was always trying to involve Group Health in broader issues such as nuclear disarmament and environmental pollution.

The book's greatest shortcoming is a lack of critical analysis, the hallmark of any scholarly history. That is not Crowley's fault; he was obviously commissioned to produce a feel-good document to celebrate Group Health's golden anniversary. Who can afford to write or publish scholarly histories? Hence a profusion of details and names are offered that brings satisfaction only to insiders. Puffery abounds. The current CEO, Phil Nudelman, is treated with reverence. For instance, we are told several times that he played a prominent role in drawing up President Clinton's 1993 health care reform proposal and was a guest of the President when the plan was unveiled. Sounds like the Titanic captain's bon voyage party. Nary a word appears about the loss of morale and the harshness involved in the firing of many Group Health employees in recent years in the name of "downsizing." In contrast, the expenditure of $400,000 to provide medical care for athletes participating in the 1990 Goodwill Games is "judged a small price for advancing international peace, and garnering national publicity." Mention is made of Group Health's public service activities in the Central District and provision of uncompensated care for indigent patients in the '60s and '70s. My own recollection is of how little Group Health performed in these spheres compared to other private hospitals, such as Providence.

None of these reservations detract from the significant contributions of Group Health, both regionally and nationally. Patient involvement in medical decision-making, the creative use of nurses, the development of family practice specialists, and a computerized patient information system including pharmacy, are but some innovations now generally accepted. From the beginning, the standards of medical practice at Group Health have been higher than in the rest of the community because physicians who were both idealistic and capable tended to be attracted to Group Health's banner, and organization-wide standards of practice were established and continually reassessed by examination of scientific evidence. A term now in current vogue, "evidence-based medicine" was practiced at Group Health before it had a name.

What are the chances that Group Health will live another 50 years? Crowley wisely offers no predictions. Being the pioneer of managed care bestows no special privileges in the savage war between health corporations who fight for "market share" by using glittery names and obnoxious radio commercials. The dilemma for Group Health is the extent to which the cost cutting deemed necessary to attract corporate benefit managers (what individual subscribers think matters little) will erode the quality of medical care provided. Walt Crowley's history should prompt us all to root for them.

To Serve the Greatest Number: A History of Group Health Cooperative of Puget Sound by Walt Crowley: Group Health Cooperative of Puget Sound/University of Washington Press, 1996. 293 pg. $19.95. Originally printed in the Seattle Weekly.

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