cover image: Interest Groups, Ideology, and Indirect Lobbying: The Rise of Private Health Insurance In the United States


Interest Groups, Ideology, and Indirect Lobbying: The Rise of Private Health Insurance In the United States

17 May 2024

This study examines the rise of private health insurance in the United States in the post- World War II era. We investigate the role of the American Medical Association (AMA) which financed a campaign against National Health Insurance that was directed by the country’s first political public relations firm, Whitaker & Baxter’s (WB) Campaigns, Inc. The AMA-WB Campaign had two key components: (1) physician outreach to patients and civic organizations; and (2) mass advertising that tied private insurance to “freedom” and “the American way.” We bring together archival data from several novel sources documenting Campaign intensity. We find a one standard deviation increase in Campaign exposure explains about 20% of the increase in private health insurance enrollment and a similar decline in public opinion support for legislation enacting National Health Insurance. We also find suggestive evidence that the Campaign altered the narrative for how legislators and pollsters described health insurance. These findings suggest the rise of private health insurance in the U.S. was not solely due to wartime wage freezes, collective bargaining, or favorable tax treatment. Rather, it was also enabled by an interest group-financed Campaign that used ideology to influence the behavior and views of ordinary citizens.
health political economy history microeconomics health, education, and welfare welfare and collective choice labor and health history other history economics of health


Marcella Alsan, Yousra Neberai, Xingyou Ye

Acknowledgements & Disclosure
The authors would like to thank Corey Purcell from the Harvard Medical School Countway Library, Jorie Braunold and Kelsey Walsh from the American Medical Association, Kim Garber from the American Hospital Association, and Beth Benham from the State Archives of the State of California for their generous assistance in accessing many of the historical resources used in this work. We thank Daron Acemoglu, Amitabh Chandra, David Cutler, Melissa Dell, Maya Durvasula, Amy Finkelstein, Price Fishback, Raymond Fisman, Paola Giuliano, Edward Glaeser, Grant Goehring, Claudia Goldin, Andrew Goodman- Bacon, Jonathan Gruber, Eric Hilt, Peter Hull, Asim Khwaja, Eliana La Ferrara, Gary Libecap, Matt Notowidigdo, Joshua Schwartzstein, Mark Shepard, Jon Skinner, Marco Tabellini, Marcos Vera-Hernandez, and seminar participants at Cleveland Clinic, Clark University, Duke University, Johns Hopkins University, Harvard Medical School Department of Global Health and Social Medicine, University of Kentucky, University of Southern California, New York University, Columbia School of Public Health, University of British Columbia, Brown University Population Studies, London School of Economics Applications Seminar, Harvard Kennedy School LIEP, NBER Development of the American Economy, NBER Economics of Culture and Institutions, Northwestern University, and Harvard Economic History for helpful comments. Jeongmook Lim, Vanessa Jia, Anne Fogarty, Michelle Wu, Maya Rosen, Anna Volpp, and Michelle Lin provided excellent research assistance. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.
Published in
United States of America

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