Why Doesn't the United States Have National Health Insurance?

This paper investigates a critical juncture in the development of national health insurance (NHI) in the United States: the post-World War II period when most peer nations moved to establish comprehensive public coverage while the U.S. did not. The authors examine the causal role of the American Medical Association (AMA), which in 1949 hired Whitaker & Baxter’s Campaigns, Inc. — the country’s first political public relations firm — to direct a nationwide campaign opposing NHI and promoting private (voluntary) health insurance (PHI).

The Campaign had two main components. First, a physician outreach component in which AMA members distributed pamphlets to patients warning against “socialized medicine” and encouraging enrollment in private plans, and acted as liaisons to local civic organizations to solicit resolutions against NHI sent to elected officials (nearly 50 million pieces of material were sent to physicians). Second, a mass newspaper advertising component, in which a standard ad was placed across newspapers nationwide, with an additional $19 million (approximately $240 million in current dollars) in coordinated tie-in advertising from roughly 23,000 corporations and industry associations. The messaging framed NHI as “un-American” and associated private insurance with “freedom” and “the American way,” providing little substantive information about insurance products.

The authors construct novel measures of Campaign exposure by combining (a) per capita pamphlets distributed by AMA physicians and (b) per capita advertising circulation scaled by local newspaper readership, using archival data from the Whitaker & Baxter Archives (Sacramento), the National Archives (Washington D.C.), digitized AMA Medical Directories, the N.W. Ayer & Son’s Newspaper Directory, and newly discovered Blue Shield enrollment data from AMA Council on Medical Service annual reports covering 1946–1954.

The primary estimation strategy exploits spatial variation in Campaign intensity combined with its timing, using event studies with state and year fixed effects and design controls for income per capita and unionization. The identifying assumption — that Campaign intensity was conditionally as-good-as-randomly assigned — is supported by balance tests showing no pre-Campaign correlation between exposure and enrollment or sociodemographic characteristics (with the exception of Black population share), and by the historical record that the Campaign was organized hastily following Truman’s unexpected 1948 electoral victory.

Main findings: A one standard deviation increase in Campaign exposure explains approximately 20% of the post-Campaign increase in PHI enrollment, corresponding to roughly 14 million additional enrollees — an effect comparable in magnitude to increasing average per capita income by approximately $100 (about 7 percent). On public opinion, a one standard deviation increase in Campaign exposure led to a six percentage point decline in popular support for NHI per Gallup survey wave, a reversal occurring against a backdrop of 69% pre-Campaign approval that was trending upward. For context, this six-point magnitude approximates the entire gap in NHI support between union and non-union households, or one-third the racial gap in support. Campaign intensity also predicts civic organizations passing resolutions favoring PHI, Republican legislators adopting speech semantically similar to Campaign propaganda, and — by 1952 — AMA members being five times more likely to donate to the Eisenhower-Nixon ticket than non-AMA physicians, with donation rates increasing in Campaign intensity.

Scope conditions: The analysis covers 48 U.S. states from 1946 to 1954, ending at the 1954 IRS tax code change that expanded commercial insurers’ market share. The enrollment data capture Blue Shield (physician-run) plans specifically; the paper explicitly notes that commercial insurer granular data are unavailable for the main Campaign period. The authors argue that multiple subsequent factors — middle-class acquisition of private coverage reducing demand for a public option, incumbent interests defending the status quo, and the persistent ideological linkage of private insurance with freedom — help explain why NHI was not adopted in subsequent decades, though these persistence mechanisms are outside the paper’s direct empirical scope.

Q: What was the AMA’s Campaign, and what prompted it? A: In response to Harry Truman’s unexpected 1948 presidential victory alongside a Democratic Congress — and with a majority of informed voters favoring NHI — the AMA hired Whitaker & Baxter’s Campaigns, Inc. to run the National Education Campaign (NEC). The Campaign had two components: physician outreach (pamphlet distribution to patients, liaison to civic organizations) and mass newspaper advertising. The AMA paid Whitaker & Baxter approximately $1.2 million per year in current terms, and coordinated an additional $19 million in 1950 dollars (roughly $240 million today) in tie-in advertising from allied corporations and trade groups.

Q: How is Campaign exposure measured, and how is it validated as conditionally exogenous? A: Campaign exposure combines two standardized components: per capita pamphlets distributed by AMA physicians (pamphlet quantity from W&B archives scaled by state AMA membership share) and per capita advertising circulation scaled by local newspaper readership (share of adults with more than five years of schooling). The two components are summed and standardized. Exogeneity is supported by balance tables showing no pre-Campaign correlation between exposure and enrollment or Gallup opinion, by the absence of discontinuous changes in income or unionization at Campaign onset, and by the historical fact that Campaign logistics relied on pre-existing networks assembled hastily in response to Truman’s unanticipated victory.

Q: What is the main effect of the Campaign on private health insurance enrollment? A: A one standard deviation increase in Campaign exposure is associated with a two percentage point increase in the share enrolled in PHI in the preferred specification (Column 4 of Table 1, which includes income, unionization, state fixed effects, and year fixed effects; coefficient 0.020, se 0.007, significant at 1%). This accounts for approximately 20% of the overall post-Campaign increase in PHI enrollment, corresponding to roughly 14 million new enrollees. The pre-Campaign coefficient is not statistically significant (coefficient 0.004, se 0.005), and the F-test p-value for pre-trends is 0.958.

Q: What is the effect of the Campaign on public opinion toward NHI? A: Using Gallup survey data, a one standard deviation increase in Campaign exposure led to an approximately six percentage point decline in individual support for NHI legislation per survey wave, against a pre-Campaign approval level of 69% that was trending upward. The F-test p-value for pre-trends in the Gallup event study is 0.179. This six-point effect is approximately equal to the gap in NHI support between union and non-union households, and approximately one-third the racial gap in support.

Q: What evidence links the Campaign to civic organizations and the legislative process? A: The Campaign’s archives document all civic organizations “on record against compulsory health insurance,” meaning they had passed resolutions in favor of PHI. The authors find a positive relationship between Campaign intensity and civic organizations passing such resolutions at the county level. Resolutions sent to elected officials were traced to the Congressional Record and to physical folders in the National Archives; their semantic similarity to AMA-WB propaganda is confirmed. Republican legislators’ speech in the 81st Congress shows increased similarity to Campaign language in proportion to Campaign intensity in their district or state, while Democrat legislators do not show this pattern. NHI and the AMA experienced spikes in mention frequency in the Congressional Record during this period.

Q: Did the Campaign affect physician political behavior beyond the clinic? A: By 1952, when the Republican platform had fully adopted the AMA’s position, AMA members were approximately five times more likely to donate to the Eisenhower-Nixon ticket than non-AMA physicians, with donation probability increasing in Campaign intensity. The authors digitized the donor list from the National Professional Committee for Eisenhower (NPCE) — a separate lobbying entity created because the AMA legally could not endorse candidates — and linked approximately 80% of physician donors to the AMA Medical Directory.

Q: What alternative explanations for PHI growth does the paper address, and how? A: The standard literature attributes PHI growth to the 1942 Stabilization Act wage freeze (which left benefits unconstrained), collective bargaining rights clarified in the late 1940s, and the 1954 IRS tax exemption for employer-paid premiums. The authors include income per capita and unionization as core design controls and show that their Campaign exposure coefficient is stable across specifications with and without these controls (coefficients of 0.025 and 0.020 in Table 1 Columns 1–2 vs. 3–4, respectively). The analysis stops in 1954 before the tax change, and the authors note that by 1952 roughly 63% of households already had some form of medical expense insurance.

Q: What is the conceptual mechanism through which the Campaign operated? A: The authors adapt Sobbrio (2011)’s indirect lobbying model. Voters hold uniform priors over whether NHI enactment yields net positive or negative social surplus. The private-sector advocate (AMA-WB) sends messages that shift voters’ posterior beliefs toward the negative-surplus state and, simultaneously, encourage PHI enrollment, which reduces voters’ private valuation of a public option. Because citizens were likely unaware of the coordinated tie-in advertising across industries and the financial motivation behind physician messaging, the framing operated through naive belief updating. The public-sector advocate (Truman administration, Committee for the Nation’s Health) was vastly outresourced — the CNH raised only $104,000 in 1949 — and faced legal constraints on executive lobbying.

Q: What advertising tactics specifically characterized the Campaign, and what do they imply about mechanisms? A: Campaign pamphlets and ads provided little or no substantive information about insurance products (coverage, eligibility, cost) and instead tied health insurance to ideological symbols: “freedom,” “the American way,” “the voluntary way,” and warnings about “socialized medicine.” Word clouds from Campaign materials confirm “America” and “freedom” as dominant terms. The authors connect this to behavioral models of advertising (Mullainathan, Schwartzstein and Shleifer 2008) whereby advertisers create or exploit associations to influence product beliefs. The absence of informational content is consistent with effects operating through ideology and identity rather than rational product evaluation.

Q: What explains why the U.S. did not adopt NHI in subsequent decades after the immediate Campaign period? A: The authors offer three mechanisms (discussed outside their main empirical scope): First, as middle-class Americans obtained PHI through employers, demand for a public option diminished — the model formalizes this as reduced private valuation of NHI. Second, incumbents who benefit from the private status quo — Blue Cross Blue Shield, AMA, American Hospital Association, and pharmaceutical companies, which today comprise four of the top ten direct federal lobbyists — actively work to maintain it (Acemoglu, Egorov and Sonin 2021). Third, the Campaign’s ideological framing proved durable: ideologically similar rhetoric opposing “socialized medicine” appeared in campaigns against both Clinton-era and Obama-era reform efforts, and has been linked to increased adverse selection and preventable deaths (Bursztyn et al. 2022; Galvani et al. 2022).

Q: What are the paper’s main contributions to the literature? A: The paper provides the first causal evidence on the AMA’s political role in blocking NHI at the post-WWII juncture, contributing to the economic history of U.S. social insurance development. It contributes to the advertising literature by providing credible estimates of a sustained national campaign combining trusted field agents (physicians) with mass media, and to the lobbying literature by documenting indirect lobbying — persuasion of ordinary citizens — as a distinct and effective tool alongside direct lobbying. It also documents physician behavior outside the clinical setting, showing how rents from supply-side constraints were deployed to shape the market for medical services.

Indirect lobbying: In the paper’s usage, persuasion of ordinary citizens via campaigns — as distinct from direct lobbying of policymakers — used to shift median voter beliefs and behavior to achieve legislative goals. Whitaker & Baxter are credited with creating this field through their work at Campaigns, Inc.

Campaign exposure: The paper’s composite treatment variable, constructed as the sum of two standardized components: per capita pamphlets distributed by AMA physicians (physician outreach) and per capita advertising circulation scaled by local newspaper readership (mass communications), then re-standardized to mean 0, standard deviation 1.

Tie-in advertising: Coordinated newspaper advertisements by third-party corporations and trade associations placed simultaneously with the main AMA-WB Campaign ad, sharing the “Voluntary Way is the American Way” slogan. Approximately 60% of newspapers with a main Campaign ad also had tie-in ads, averaging three per issue; third-party spending totaled approximately $19 million in 1950 dollars (~$240 million current).

Voluntary (private) health insurance: In the paper’s framing, the AMA-promoted alternative to NHI — prepaid medical service plans run by state medical societies (Blue Shield) or nonprofit hospitals (Blue Cross) — deliberately labeled “voluntary” to contrast with “compulsory” NHI, embedding the product within an ideological frame of free choice.

National Education Campaign (NEC): The AMA’s official name for the anti-NHI campaign directed by Whitaker & Baxter starting in 1949, characterized as “educational” to provide legal cover; the name itself illustrates the indirect lobbying strategy of framing political advocacy as public information.

Source text origin / abstract-only block: Not a paper-defined concept; excluded.

Naive voter updating: The paper’s modeling assumption (drawn from Sobbrio 2011) that voters held uniform priors on health insurance policy outcomes and updated beliefs via Bayesian message receipt, without awareness of coordination across industries or the financial motivation of physician messengers — making the ideological framing effective.

Physician field agents: In the Campaign’s design, AMA member physicians served as credible, trusted intermediaries who distributed pamphlets to patients and solicited civic organization resolutions, leveraging their social status to amplify the Campaign’s reach into communities where mass advertising alone would be insufficient.