A New Kind of Issue Advocacy
Although rewarded generously for their efforts, Whitaker and Baxter were not simply guns for hire. The business model they developed fit comfortably with their broader ideological commitments. Whether working on behalf of a ballot measure or a candidate, Whitaker and Baxter saw themselves as defenders of free enterprise against the steady encroachments of an overreaching state. Nowhere is this more evident than in their work to defeat proposals for government-provided health insurance, first in California and then on the national stage. Without Whitaker and Baxter, “socialized medicine” might not have become the politically loaded phrase it is today. However, the pair contributed more than a mere slogan to American politics. Whitaker and Baxter’s work mobilizing doctors represented a new kind of issue advocacy, and their success promoting the virtues of private insurance shaped the trajectory of US health policy for decades to come.
Whitaker and Baxter’s first battle in the health care wars began with the campaign to defeat Governor Earl Warren’s plan for universal health coverage in California. Although Warren himself was a former client—Campaigns, Inc. managed his successful run for governor in 1942—Warren’s national aspirations and liberal inclinations increasingly put him at odds with Whitaker and Baxter’s conservative views. Preparing for a re-election campaign in 1946 and eyeing a possible presidential run in 1948, Warren embraced universal health care as an issue that could secure a record of accomplishment and raise his profile before a national electorate. With these goals in mind, Warren submitted a bill to the California Assembly in January 1945 to provide health care to Californians through a system of public insurance financed by a new payroll tax.54 Although Warren anticipated some opposition to the plan from doctors, the medical profession in the state was poorly organized. In Carey McWilliams’s words, doctors had “little political influence and a notoriously inept sense of public relations.”55 This was about to change dramatically.
Soon after Warren announced his health insurance plan, the California Medical Association (CMA) hired Campaigns, Inc. on a $25,000 annual retainer to coordinate opposition against the governor’s bill.56 As they had done in other campaigns, Whitaker and Baxter sought to mobilize opposition to the Warren Plan while building up public support for a well-defined alternative. More precisely, Whitaker and Baxter recommended that doctors embrace and promote voluntary private health insurance as an alternative to the public provision of care. Outlining their strategy in April 1945, Clem Whitaker warned the CMA that defeating the Warren Plan “will require more than just defensive action. ... It will require affirmative action to make pre-paid medical and hospital service available to all the people on a voluntary basis . so that the proponents of government medicine will be stripped of all effective argument for their program of compulsion.”57 With widespread adoption of private insurance in California, Whitaker predicted that “compulsory health insurance will be dead as a legislative issue—and neither Governor Warren nor any other Governor will have the effrontery to disinter the remains.”58
Whitaker and Baxter’s plan required a fair bit of salesmanship, not least among doctors themselves. In the early 1940s, private health insurance covering hospitalization and medical services was still in its infancy. In 1939, the CMA created the nation’s first Blue Shield plan, offering prepaid medical care through the California Physicians’ Service (CPS). Public reception of prepaid care was fairly tepid, and many doctors remained opposed to any form of insurance, private or public, for fear that it would lead to negotiated prices and lower fees.59 Whitaker and Baxter sought to change doctors’ perception of private insurance, arguing that “we can think of no better protection the medical profession can have against . government regimentation than a strong, successful CPS.”60 Consequently, Whitaker and Baxter advised the CMA that the best way to defeat public health insurance was “to overcome all opposition to [private insurance] in the medical fraternity, so that the system can function effectively in every section of the State.”61 Their goal, in short, was “to develop and expand California Physicians Service, and all other acceptable voluntary medical and hospital systems, . [so] that the majority of the people, who need pre-paid health coverage, will have it before our campaign is ended.”62
For the adoption of private health insurance to succeed, Whitaker and Baxter conceived a massive public relations campaign guided by a simple message: “The Voluntary Way Is the American Way.”63 As Whitaker and Baxter put it in their campaign literature, “There is nothing that Government can do for citizens in the field of health insurance which they cannot do better themselves—and do at less cost!”64 But voluntary health insurance did more than protect against the costs of unexpected illness; it provided a vital bulwark against “a rigid system of government regimentation, conceived in goose-stepping Germany, [that is] utterly foreign to our American way of life.”65
Whitaker and Baxter’s portrayal of the Warren Plan as both a threat to the American health care system and a violation of deeply held American values tapped into the sentiments of a postwar public weary of price controls and wary, perhaps, of the growing reach of the modern state. Sensing these concerns, Whitaker and Baxter sought to convince doctors that their struggle against the Warren Plan had implications that reached beyond the borders of California. Outlining their strategy for the California Medical Society in 1946, Whitaker and Baxter wrote that the debate over health policy was “a crusade which will echo throughout the United States,” adding that “California has been the testing ground for a great many visionary schemes and phony movements—but it has also become the burial ground for most of them,” an oblique reference to their success in defeating Upton Sinclair’s campaign for governor and, later, a statewide plan for old-age pensions.66 In fact, California was a laboratory for a conservative message that would go on to shape national health care debates, from President Truman’s campaign for universal coverage in 1948 to the contentious struggle over the Affordable Care Act in 2010. Whitaker and Baxter’s extended influence over health policy attests to their skills in crafting messages, as well as their ability to intuit the preferences and prejudices of the public.
Whitaker and Baxter were guided by more than feel: their reading of opinion also relied on the latest techniques in survey research. In 1945, Campaigns, Inc. contracted a market research company, Knight and Parker Associates, to carry out a statewide survey of opinion about health insurance. As Whitaker and Baxter explained, the results of the survey provided “a preliminary test of some of the arguments which are effective in influencing public sentiment on this question.”67 In particular, Whitaker and Baxter discovered fairly wide support for public health insurance in principle but a widespread concern that “state medicine” would result in lower-quality care. According to Whitaker and Baxter, “This fear of incompetent doctors, inferior service and assembly-line medical methods undoubtedly represents the No. 1 argument against compulsory health insurance with rank and file voters.”68 At the same time, the Knight and Parker survey revealed that among respondents whose families were covered by private insurance, more than 70 percent were satisfied with their private plan.69 As Whitaker and Baxter told the CMA, “The general public satisfaction with the service being rendered ... would seem to indicate that a stepped-up drive to expand [private insurance] would be highly successful and would help spike the guns of those advocating compulsory [public insurance].”70 In addition, the survey reported that women were more suspicious of public insurance than men, leading Whitaker and Baxter to conclude that “doctors’ wives should play a vital part in lining up the leading women in their communities to . work against the [Warren Plan].”71
Bolstered by the survey results, Whitaker and Baxter used public concerns about the quality of care as the basis for a massive campaign to promote sales of private health insurance policies in California. Over a period of three years, Campaigns, Inc. spent $367,470 on pamphlets, newspaper advertisements, and even a dedicated weekly radio program extolling the virtues of private insurance.72 The centerpiece of the publicity effort was Voluntary Health Insurance Week, a series of carefully planned events, public meetings, and advertising efforts designed to “dramatize the crusade” and attract “enthusiastic news and editorial support” for private health insurance.73 Using a system of county campaign committees led by “an able, aggressive doctor,” Voluntary Health Insurance Weeks transmitted a carefully crafted set of messages formulated by Whitaker and Baxter at their headquarters in San Francisco.74 By 1948, fifty-three of fifty-eight counties held insurance weeks throughout the state.75
With meticulous precision, Whitaker and Baxter reported multiple measures of their success: more than 400 newspapers opposing public health insurance compared with only 20 in favor; 200 civic organizations and 100 chambers of commerce on record against public insurance; 120 mayors enrolled to serve as chairmen of Health Insurance Weeks; and tens of thousands of inches of newspaper space in advertising, news coverage, and editorials all opposed to the Warren Plan. Moreover, Whitaker and Baxter pointed out that since the Warren Plan nearly passed the California Assembly by a single vote in 1946, no bill on behalf of public insurance had even made it out of committee. Finally, Whitaker and Baxter took partial credit for the fact that membership in the California Physicians’ Service had quadrupled since their publicity campaign began, while enrollment in private insurance schemes had doubled to more than 5 million people throughout the state.76
In spite of these developments, some members of the California Medical Association expressed concern that a public relations campaign diminished the professional standing of doctors. Others wondered if the extraordinary cost of these efforts was worth it. Rankled by such complaints, Whitaker and Baxter reiterated the high stakes involved. Responding to their critics in the CMA, Whitaker and Baxter wrote, “Your profession is in the front lines in one of the most critical struggles in the history of this Nation—a basic struggle between ... socialism and capitalism. ... Call it what you like, it is a war to the death.”77 Hyperbole aside, the continued skepticism toward Campaigns, Inc. and its methods testifies both to the novelty of their practices and the challenges Whitaker and Baxter faced in creating a powerful medical lobby in the United States. Drawing parallels between the medical profession and their own status as trained experts, Whitaker and Baxter informed their clients that “in public relations, as in medicine, it is of first importance that you have confidence in your doctor. And if at any time you lack that confidence, then you should change doctors.”78 At the same time, Whitaker and Baxter insisted that their methods were a critical weapon in the fight for free enterprise, upbraiding those physicians who held on to “the specious dogma that doctors shouldn’t muddy their togas in the field of politics.”79 Instead, doctors needed to see themselves in common cause with other business interests fighting against the encroachments of the modern state. A sustained campaign of public relations waged through modern channels of communication was simply “the price of liberty” to maintain “the dignity of a free profession, [and] of men.”80
If doctors had some doubts about their methods, others recognized the importance of Whitaker and Baxter’s achievement. As Carey McWilliams put it, “Whitaker and Baxter [wrote] a political script in which doctors, originally cast as special-interest heavies, emerge [d] as crusaders for the people’s health. This is expert political management; this is government by Whitaker and Baxter.”81 In fact, doctors around the country took notice; several directors of state medical societies requested material and advice from Campaigns, Inc. in waging their own fights against public health insurance.82 And in 1949, when
President Truman staked his presidency on the enactment of a national health insurance plan, the American Medical Association came calling.
Whitaker and Baxter’s work on behalf of the American Medical Association in many ways represents the apotheosis of all they had learned and accomplished in California. In both form and content, the campaign to defeat Truman’s push for national health insurance reproduced many of the same themes and tactics the team successfully employed against Governor Warren several years earlier, only on a larger scale. Scholars have rightly viewed the AMA campaign as a pivotal moment in the history of American health policy.83 In addition, the AMA fight against national health insurance marks a broader development in American politics: the rise of professionally managed issue advocacy campaigns. Although such tactics look familiar today, the AMA effort was remarkable for its time in both sophistication and scope.84
Whitaker and Baxter came to the attention of the AMA in 1948 as the prospects for a political breakthrough in national health insurance brightened. In May, Truman convened the National Health Assembly, at which he reiterated his commitment to improving the health and health care of all Americans. In September, Oscar Ewing, chairman of the Federal Security Administration, presented Truman with a report, The Nation’s Health—A Ten Year Program, that outlined plans for a federal system of compulsory health insurance. With Truman’s unexpected election victory in November and Democratic majorities in both chambers of Congress, the goal of national health insurance seemed within reach.85
Three weeks after the election, Clem Whitaker traveled to St. Louis, where he appeared before the National Medical Public Relations Conference. Organized under the auspices of the AMA, the meeting promoted the value of public relations techniques to the medical profession and included workshop sessions titled “Using Public Relations to Promote Medical Prepayment Plans” and “Selling the Need for Public Relations to State Medical Society Members.”86 Whitaker, who McWilliams described as “a masterful speaker and a superb salesman,” used his appearance in St. Louis to convince the AMA leadership in attendance that Campaigns, Inc. should lead the effort against Truman’s health plan.87 A few weeks later, an AMA press release announced it had retained the firm “to direct the organization’s forthcoming campaign against the threat of socialized medicine.”88 In February 1949, Whitaker and Baxter set up shop in Chicago, Illinois, home to AMA headquarters, and established the National Education Campaign. As their practice had been in California, Whitaker and Baxter demanded complete control over the campaign and its finances. To that end, the AMA levied a $25 assessment on each member. Although a minority withheld dues in opposition to the outright politicking of the AMA leadership, the organization quickly amassed an ample war chest of $2.25 million for the campaign.89 For their part, Whitaker and Baxter received an annual fee of $ioo,ooo.90
As they had done in California, Whitaker and Baxter framed the issue as a choice between private health insurance and a compulsory, government-run program, the first step toward a creeping and dangerous socialism. Whitaker and Baxter even recycled some of the same language from the California campaign, using slogans such as “The Voluntary Way Is the American Way” to extol the virtues of private insurance as an alternative to public provision.91 As before, the goal was to conjure images of government bureaucrats deciding who was to receive health care and when. “The challenging and tremendous task we have undertaken,” Clem Whitaker told the AMA House of Delegates in 1949, “[is] to alert and awaken the American people to the danger which threatens them; to crystallize and mobilize public opinion, so that the people’s mandate on this issue shall be unmistakable.”92
In outlining their strategy, Whitaker and Baxter realized not only that health care touched upon very personal connections between patients and their doctor but that physicians themselves constituted a national network of highly respected “opinion leaders” who could carry the AMA message directly to the public.93 To capitalize on this potential, Whitaker and Baxter directed much of their effort toward engaging doctors in the fight against national health insurance. As Leone Baxter put it, “The medical profession has a vitally important story to tell, and who in the world is to tell it ... with more truth or with more sincerity than doctors themselves?”94 From campaign headquarters in Chicago, Whitaker and Baxter sent pamphlets to doctors throughout the country for distribution to their patients. Posters of the well-known painting by Luke Fildes of a doctor carefully attending to a sick child in his home as his grateful parents looked on hung in more than 40,000 physician waiting rooms, accompanied by the caption, “Keep Politics Out of This Picture!” As Baxter explained, “The painting of the doctor may be old fashioned in some respects. ... But there is something in that picture which represents one of the most priceless possessions you men of medicine have in your whole fight against assembly line medicine ... compassion.”95 It was this ability to craft compelling, impassioned appeals that made Whitaker and Baxter so effective. As Stanley Kelley put it, “They tried to present their case in a way that would have meaning to the individual citizen, to translate public issues into private
In addition, Whitaker and Baxter understood how to convey their core message through all variety of media so as “to effect maximum reiteration . from as many apparently independent sources as pos- sible.”97 Scores of pamphlets, press releases, and other literature were issued from the National Education Campaign to doctors, state medical societies, and women’s auxiliaries made up of physicians’ wives. As in California, Whitaker and Baxter paid particular attention to women as an influential group who were receptive to the message about the perils of national health insurance. As Whitaker explained, “Women are realizing they will not only pay their doctor bill under socialized medicine; but they will pay a double bill—for hordes of bookkeepers, clerks, bureaucrats, and personnel.”98 In addition, women feared “there would be a general deterioration of care” as a result of an “assembly-line type” of state medicine. Federations of Women’s Clubs in nine states went on record against the Truman Plan.99 Similarly, other groups believed to be receptive to Whitaker and Baxter’s message received special appeals from the AMA. By the end of 1949, more than 1,800 allied organizations announced their opposition to national health insurance, with thousands more joining the ranks over the next three years. Newspaper editors received regular correspondence from the national campaign, while a publicity firm in Portland, Oregon, distributed canned editorials for reprint in rural newspapers.100 A massive advertising buy attacking “socialized medicine” appeared in full-page display in 11,000 newspapers, while spot radio announcements ran on 1,000 stations across the country.101 Explaining his strategy, Clem Whitaker wrote, “We want the terrific impact of all the media hitting at once,” so that
“medicine’s story can be hammered home by repetition.”102 All of this was designed to convey the impression of massive, widespread support for the AMA position and the virtues of private health insurance.
According to Whitaker, such a broad-gauge effort was essential to counteract “the tremendous power of the government propaganda machine ... beating the drums for socialized medicine.”103 In truth, the AMA effort exceeded anything the Truman administration accomplished or even contemplated on its behalf. In 1949, the National Education Campaign distributed more than 54 million pieces of mail at a cost of over $1 million, with another 43 million pamphlets sent out the following year. In 1950, the AMA Board of Trustees approved an advertising budget of $1.1 million for newspapers, radio, and national magazines, most of it spent over a two-week period in advance of the midterm election.104 According to Congressional Quarterly, the AMA spent a total of $3.6 million on the National Education Campaign between 1949 and 1952. During the first two years of the campaign alone, the AMA accounted for more than 15 percent of all reported lobbying expenditures, making doctors the best-financed and arguably the most formidable lobby of the day.105
In their work for the AMA, Whitaker and Baxter helped develop a new kind of advocacy in which a coalition of like-minded actors came together under the banner of a single issue. Success required, first and foremost, convincing physicians that their personal and economic interests could only be advanced through political organization. Speaking to an audience of doctors in 1949, Baxter underscored the “need to give a demonstration throughout the nation at this time of the unanimity of the medical profession.”106 The fate of doctors overseas under the National Health Service offered a cautionary tale. “The final force that crumpled British medicine,” Baxter told the AMA in 1949, “was simply the inability to get together and stay together.”107 Complementing this strategy was the promotion of private insurance as an alternative not only to make public insurance less desirable but also to bring the insurance industry along in the effort. Health and accident insurance groups, sensing their stake in the issue, contributed significantly to the advertising campaign against the Truman Plan.108
As the pair learned in California, health care motivated a broader set of ideological concerns perfectly attuned to the growing postwar debate over the nature and scope of American government. The struggle against national health insurance concerned more than just doctors or the insurance industry. As Whitaker put it, “The concentration of power in Washington is frightening, and the constant reach for more power is unending. It is only a short step from the ‘Welfare State’ as our Washington planners envision to the ‘Total State,’ which taxes the wage earner into government enslavement, ... stamps out incentive and soon crushes individual liberty.”109 This was a message with potentially broad appeal, and Whitaker and Baxter used the threat of national health insurance to enlist the support of a range of allied groups, including the American Farm Bureau Federation, the American Bar Association, and the National Association of Small Business.110
Emboldened by their success in defeating Truman’s goals for national health insurance, Whitaker and Baxter sought to use health care as an electoral issue in congressional contests and as a way to organize groups on behalf of the Republican Party. According to Stanley Kelley, Whitaker prepared a campaign plan entitled “The Power of a Single Issue Aggressively Sold to the Voters” in which he outlined strategies to enlist doctors to work on behalf of Republican candidates.111 This included examples of form letters doctors should send their patients encouraging them to vote for candidates who “consistently and firmly opposed compulsory sickness insurance,” explaining that “you and your family will be far better off under voluntary plans ... with complete freedom to choose your own doctor.”112 Other letters struck a more ominous tone: “Your doctor’s service is being threatened by both the outside invasion of socialists who are trying to tell us how to vote in Tuesday’s election and by the ideology of socialized medicine which the invaders are trying to force upon us.”113 In a special election in New York for the US Senate in 1949, doctors sent 2.4 million letters to patients urging them to vote against Democrat Herbert Lehman. Although Lehman won that race, Democratic candidates in Utah, Nebraska, and Wisconsin lost their seats in part due to the involvement of doctors.114 These efforts on behalf of congressional candidates became a template for the 1952 Republican presidential election. With the National Education Campaign winding down, Whitaker and Baxter joined the former chairman of the AMA Coordinating Committee, Dr. Elmer Henderson, to form the National Professional Committee for Eisenhower and Nixon. Its goal, the New York Times reported, was to “enlist medical, dental, legal, engineering and other professional men and women” in support of the Republican ticket.115
More than sixty years later, the same strategies and tactics Whitaker and Baxter employed in the fight against national health insurance are evident in the ongoing struggle over health care reform. During debates over passage of the Affordable Care Act, the bugaboo of socialized medicine and government bureaucrats run amok resurfaced in the rumors of federal death panels that would supposedly dictate who among the elderly would receive care. In fact, the long shadow of Whitaker and Baxter extends beyond the rhetoric over health policy. Emboldened by their success against Truman, the AMA leadership embarked on an ambitious and at times arrogant political agenda that diminished support for the organization among doctors and led to declining political influence for the profession. As historian Christy Ford Chapin documents, AMA missteps would later haunt physicians as the insurance industry gained in strength, both politically and economically, at the expense of doctors who saw their power over the provision of care steadily erode.116
In fact, Whitaker and Baxter’s influence over American politics extends even further. Unrealized at the time, Whitaker and Baxter foreshadowed the rise of the modern conservative movement in American politics.117 By turning policy debates over health insurance into a Manichean struggle over personal freedom, Whitaker and Baxter at once set the outer limits of the New Deal state and developed a powerful message that would, in time, pay rich political dividends for the Republican Party. In what would become a core conservative strategy, Whitaker and Baxter leveraged the vast financial resources of American business to foster an antigovernment skepticism among the American people.