This article examines how the American Medical Association (AMA) helped shape the development of the U.S. health insurance system in the critical period after World War II. Working with the political public relations firm Campaigns, Inc., the AMA launched a nationwide campaign to weaken support for national health insurance by framing it as “socialized medicine,” while simultaneously enrolling people in private health insurance plans to shift demand away from a public alternative. Drawing on newly assembled archival data, we find that greater exposure to the campaign explains about 20% of the rise in private health insurance enrollment and a comparable decline in public support for a national program. The campaign also appears to have influenced policy making through coordinated messaging, resolutions passed by civic organizations, congressional rhetoric, and political donations. These findings suggest that the rise of private health insurance in the United States was not solely due to macroeconomic forces or collective bargaining; rather, it was also enabled by a strategic, interest group–financed effort to shape citizen views and influence policy.

The TseTse fly is unique to Africa and transmits a parasite harmful to humans and lethal to livestock. This paper tests the hypothesis that the TseTse reduced the ability of Africans to generate an agricultural surplus historically. Ethnic groups inhabiting TseTse-suitable areas were less likely to use domesticated animals and the plow, less likely to be politically centralized, and had a lower population density. These correlations are not found in the tropics outside of Africa, where the fly does not exist. The evidence suggests current economic performance is affected by the TseTse through the channel of pre colonial political centralization. (JEL I12, N57, O13, O17, Q12, Q16, Q18)

We study the effects of Secure Communities, an immigration enforcement program that dramatically increased interior removals of Hispanic noncitizens from the United States, on participation in means-tested social insurance programs among co-ethnic citizens. Exploiting county-level variation in the roll-out of enforcement together with its ethnic specificity, we find that Hispanic-headed citizen households significantly reduced their participation in two large federal safety net programs. Our results are most consistent with network effects that propagate fear through minority communities rather than stigma or lack of benefit information.

We study the effect of physician workforce diversity on the demand for preventive care among African American men. In an experiment in Oakland, California, we randomize black men to black or non-black male medical doctors. We use a two-stage design, measuring decisions before (pre-consultation) and after (post-consultation) meeting their assigned doctor. Subjects select a similar number of preventives in the pre-consultation stage, but are much more likely to select every preventive service, particularly invasive services, once meeting with a racially concordant doctor. Our findings suggest black doctors could reduce the black-white male gap in cardiovascular mortality by 19 percent. (JEL I12, I14, C93)

I14, O15 For forty years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black males with syphilis despite the availability of effective treatment. The study's methods have become synonymous with exploitation and mistreatment by the medical profession. To identify the study's effects on the behavior and health of older black men, we use an interacted difference-in-difference-in-differences model, comparing older black men to other demographic groups, before and after the Tuskegee revelation, in varying proximity to the study's victims. We find that the disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men. Our estimates imply life expectancy at age 45 for black men fell by up to 1.5 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women.

A long-standing and influential view in U.S. correctional policy is that “nothing works” when it comes to rehabilitating incarcerated individuals. We revisit this hypothesis by studying an innovative law-enforcement-led program launched in the county jail of Flint, MI: Inmate Growth Naturally and Intentionally through Education (IGNITE). We develop an instrumental variables approach to estimate the effects of IGNITE exposure, leveraging quasi-random court delays that cause individuals to spend more time in jail before and after the program’s launch. Holding time in jail fixed, we find that one additional month of IGNITE exposure reduces weekly misconduct in jail by 25% and three-month recidivism by 24%, with the recidivism effects growing over time. Surveys of staff and community members, along with administrative test-score records and within-jail text messages, suggest that cultural change and improved literacy and numeracy scores are contributing mechanisms.

We explore the first period of sustained decline in child mortality in the U.S. and provide estimates of the independent and combined effects of clean water and effective sewerage systems on under-five mortality. Our case is Massachusetts, 1880 to 1920, when authorities developed a sewerage and water district in the Boston area. We find the two interventions were complementary and together account for approximately one-third of the decline in log child mortality during the 41 years. Our findings are relevant to the developing world and suggest that a piecemeal approach to infrastructure investments is unlikely to significantly improve child health.

This article examines the consequences and causes of low enrollment of Black patients in clinical trials. We develop a simple model of similarity-based extrapolation that predicts that evidence is more relevant for decision-making by physicians and patients when it is more representative of the group being treated. This generates the key result that the perceived benefit of a medicine for a group depends not only on the average benefit from a trial but also on the share of patients from that group who were enrolled in the trial. In survey experiments, we find that physicians who care for Black patients are more willing to prescribe drugs tested in representative samples, an effect substantial enough to close observed gaps in the prescribing rates of new medicines. Black patients update more on drug efficacy when the sample that the drug is tested on is more representative, reducing Black-white patient gaps in beliefs about whether the drug will work as described. Despite these benefits of representative data, our framework and evidence suggest that those who have benefited more from past medical breakthroughs are less costly to enroll in the present, leading to persistence in who is represented in the evidence base.

Can information from a credible messenger shift behavior in an information-saturated environment? In a randomized controlled trial involving twenty-eight million individuals in West Bengal, we find that SMS-delivered video messages containing information about COVID-19 symptoms and health-preserving behaviors recorded by a credible messenger increased adherence to targeted and non-targeted preventive behaviors, measured by two objective measures (symptoms reported to a health worker, and phone usage at home), as well as self-reported behaviors. We find large spillovers onto non-targeted recipients. Credible light-touch messaging can play an important role in crisis response, even when similar information is widely available.