By Dave Chase – September 28, 2026
In 1899, sixty members of the Catholic Workers’ Association in Switzerland promised to help carry each other’s costs when illness or accident struck. That promise became CSS, which now insures about 1.7 million people, almost one in five Swiss, and still belongs to the association that grew from its founders.
Similar stories run across Europe. In Germany, Bismarck built national health insurance in 1883 on the sickness funds workers had already started and kept their self-governing boards. About 88 percent of Germans are covered through those funds today. In Belgium, mutual societies with Christian, Socialist, and Liberal roots co-administer compulsory coverage, so communities that disagree on nearly everything each run part of one national system. The Christian mutual alone has more than four million members, over a third of the country. France’s mutuelles trace back to medieval guilds, and in 1957 a Barcelona physician founded a mutual governed by doctors and patients that grew into a national cooperative network.
Cooperatives are one proven road among several. The UK, Canada, and Australia reached universal coverage through direct state action. In Germany and Belgium, member-governed funds became the operating layer of universal care, and governments across the political spectrum chose to keep them.
The American attempt
In 2010 the Affordable Care Act funded 23 nonprofit CO-OPs, and twenty failed within a decade. They were created on a federal timeline, topdown (oxymoronic to a real cooperative), barred from marketing, and barred from hiring experienced insurance leaders. Then Congress cut the risk-corridor payments it had promised. They carried the cooperative name without members who already needed each other, the foundation that let the European funds last for generations.
Wisconsin shows the authentic version
The Employers Health Cooperative of Wisconsin grew out of one school district, Rice Lake, which began rebuilding its health plan in 2017. Neighboring employers asked to join, and in 2021 a school business manager suggested a cooperative because districts already share services they can’t afford alone. EHCW grew from 750 covered lives in 2021 to 23,000 by June 2026. Primary care is free to employees, and member groups average 22 percent better cost performance than comparable Wisconsin employers.
What it means for capital and policy
Rural electrification gave America the playbook: patient federal capital, model state legislation, and engineering help, with local cooperatives doing the building. Default rates stayed under 1 percent, and about 900 of those cooperatives still serve 42 million Americans, roughly one in eight of us. The Community Self-Determination Framework I’ve shared with policy partners applies that template to health: capital follows grassroots demand, and covenants keep community plans in community hands.
For impact investors, a cooperative health plan is ownership in the literal sense: the employers, workers, and neighbors who pay the bills hold the ownership and the votes. Health Rosetta, a Public Benefit Corporation and Nautilus Health Institute are building the practitioner network and open-source standards those plans need to start strong. For Health Rosetta advisors, the opportunity is already on your client list, in every cluster of employers facing the same hospital prices alone.
Go slow to go fast. Go local to go national. Start small to go big. That’s always been the American way. Fire departments, schools, postal service, rural electricity and so much more grew this way. As the system is breaking down and fracturing (already happened in rural America), drawing on historical lessons from the U.S. and abroad show the way out of the mess.
I go deeper on the European history, the CO-OP lessons, and the Wisconsin story on Substack: When Neighbors Built the Health System. The full EHCW case study is in Relocalizing Health, free to download at healthrosetta.org/friends.