In the early 20th century, most people paid for doctor visits or hospital care out of pocket, according to University of Maine professor of finance Pankaj “Pank” Agrrawal. There was charity care, mutual societies and employer programs, but public health was focused more on preventive care rather than curing people.

Health insurance packages grew in popularity after World War II in a competitive labor market, according to Jason Harkins, executive dean of the University of Maine Business School. With wage controls in place at the time, employers started offering pensions and other benefits, including health insurance. It became so popular that it influenced the entire health care industry.

“You saw the addition of health insurance, so there were a lot of benefits added to … employees in order to attract and retain talent,” he said. “And once you have a number of people on an employer-provided health care plan or a health insurance plan that then starts to change the dynamics of what’s happening within the health care industry.”

When the federal government wanted to start helping poor and elderly people access health care in the 1960s, it developed Medicare and Medicaid, modeled after health insurance. Then the ’70s and ’80s saw a rise in managed care, which is a way insurance companies keep health care costs low while also trying to ensure that efficient but quality care was provided to patients.

The Affordable Care Act, rolled out in the 2010s, increased access to health insurance for those who were uninsured, eventually cutting the rate of uninsured people roughly in half, Agrrawal said. More people are also talking about the idea of universal health care, in which all citizens are entitled to access to health care.

Doctors used to work for themselves or in private practices, Harkins said. They would negotiate their own prices and rates, but there has been a lot of consolidation over the years and many health care provisions have been put into place to help more people gain access to care. One result is that health care systems have grown large, impacting insurance companies’ ability to pay.

In response, doctors are now required to spend a lot of time fulfilling insurance requests and paperwork to get care covered, which is impacting their ability to see patients, he said.

“A huge portion of their overhead goes to submitting and then resubmitting and then refining and then resubmitting these insurance requests in order to get compensated for their work,” Harkins said.