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The Blue Cross and Blue Shield Association is the largest private health insurance system in the United States (including Puerto Rico) and Canada. It is composed of 55 independent, locally operated Blue Cross and Blue Shield Plans that collectively provided health care coverage to over 88 million people in 2003.

For its beginnings we need to go back to 1929 to a man named Justin Ford Kimball when he became vice president of Baylor University in Dallas, Texas. He was an experienced administrator, as he headed the College of Medicine, School of Nursing, College of Dentistry, and the university hospital.

Soon after taking the job, he developed a health plan that guaranteed teachers 21 days of hospital care for 50 cents a month. The plan soon spread to other employee groups in Dallas, and then similar plans began to crop up nation-wide.

Meanwhile, around the same time that Kimball was creating his plan, the Blue Shield concept was becoming popular in the lumber and mining camps of the Pacific Northwest. Serious injuries and chronic illness were common among these workers who were in very hazardous and dangerous jobs.

Their employers saw the need to provide medical care for them and they arranged with physicians to pay them a monthly fee to take care of the medical needs of the workers. These programs would later become what is known as the Blue Shield Plans.

As for the cross symbol, it was first used in a 1934 advertisement for the Hospital Service Association, which later became known as Blue Cross and Blue Shield of Minnesota.

Joseph Binder, a Viennese artist, was hired by Company secretary E.A. van Steenwyk to create a poster that included a blue Greek cross. Van Steenwyk used the symbol to identify his company's health plans and then Blue Cross began to use it in other parts of the country.

In 1939, the American Hospital Association, which was based in Chicago, began to use the Blue Cross symbol to indicate that health plans around the country met certain standards.

The AHA continued to use the symbol until 1960 when the Blue Cross Association was founded. The two organizations remained affiliated until 1972.

The shield symbol was created in Buffalo, New York by Carl Metzger in 1939 and the first official Blue Shield plan was founded in California that same year. Carl Metzger was an early pioneer in the Blue movement and he wanted a design that would distinguish the new medical service plan.

It soon flourished as the number of Blue Shield Plans kept on growing. In 1948 the symbol was informally adopted by nine plans called the Associated Medical Care Plan, which was later renamed the National Association of Blue Shield Plans.

Over the years, the Blue Cross and Blue Shield healthcare insurance concepts took hold. The Blue Cross Blue Shield Association was formed in 1982 by a merger of the Blue Cross Association and the National Association of Blue Shield Plans. When the Blue Cross and Blue Shield organizations merged, their brand symbols also merged and became one of the most familiar symbols in America.

To show you how large it has become, in 2003, the Blue Cross and Blue Shield Association took in $182.7 billion in revenue. The evolution of managed health care in the United States is intimately linked to the designs of Blue Cross- Blue Shield.