In July 2025, a peer-reviewed study published in PLOS Global Public Health completed a systematic analysis of 1,675 paid advertisements that the Partnership for America’s Health Care Future ran on Facebook and Instagram between 2018 and 2021. The study was led by researchers at the London School of Hygiene and Tropical Medicine. Its conclusions were precise.
The researchers found that PAHCF’s advertising campaign was designed to increase public doubt about the benefits of healthcare reform, undermine trust in government and evidence, and promote alignment with industry messaging — using tactics that directly mirrored the strategies historically deployed by the tobacco industry, the alcohol industry, and the ultra-processed food industry.
The comparison is not rhetorical. The study applied an established analytical framework — the commercial determinants of health — that has been used to document how industries whose products or practices cause harm systematically construct public doubt about that harm to protect their profits. The same framework that documented how tobacco companies manufactured uncertainty about the health effects of smoking identified the same strategic structure in PAHCF’s healthcare advertising.
This is where the strategy behind the previous five articles in this series comes from. It did not originate with the healthcare industry in 2018. It was developed over decades by industries facing the same structural threat — scientific evidence and public sentiment moving toward regulation of practices that generated profits — and refined into a documented playbook that has been applied across sectors. The healthcare industry hired the people who built that playbook and applied it to healthcare reform.
The Playbook and Its Origins
The tobacco industry’s campaign to manufacture doubt about the health effects of smoking is the most thoroughly documented case of a corporate disinformation strategy in American history. Internal tobacco company documents, released through litigation and the 1998 Master Settlement Agreement, established the strategy in precise terms: identify the emerging scientific consensus, fund alternative research to create the appearance of scientific uncertainty, build industry front groups that look like independent public interest organizations, cultivate media relationships that ensure the “both sides” framing of settled science, and work the legislative and regulatory environment to delay action until the appearance of uncertainty can be maintained.
The same documented playbook, with adaptations for medium and moment, appears across the record of PAHCF’s operation: the front group that presents as a patient advocacy coalition while being funded by the industries it nominally represents; the manufactured grassroots opposition documented in Article 4; the surrogate network of credentialed voices carrying industry messaging without visible industry attribution; the advertising campaign designed not to make arguments but to generate doubt and anxiety; and the legislative environment construction documented in Article 3 that shapes what candidates adopt before they reach office.
Chip Kahn, the Federation of American Hospitals CEO who took public credit for founding PAHCF and who created the “Harry and Louise” campaign against the Clinton healthcare plan in the 1990s, is not merely a practitioner of this strategy. He is a direct institutional link between the healthcare industry’s current operations and the earlier period when these strategies were being developed and refined across multiple industries. The “Harry and Louise” campaign was itself modeled on earlier insurance industry campaigns against national health insurance proposals stretching back to Harry Truman’s administration in the late 1940s.
The strategy has a seventy-year documented history of application to healthcare reform specifically — predating PAHCF by decades, predating Chip Kahn’s career by decades, and representing an institutional inheritance that any successor coalition would deploy without needing to develop it from scratch.
Where the Strategy Has Limits
The PLOS study documented the strategy’s mechanics. The current public opinion landscape documents its limits.
The attack line that PAHCF’s advertising campaign made central — Medicare for All would eliminate private insurance and require higher taxes — produced reliable erosion of support when tested in polling during the 2018 to 2020 period. When survey questions led with this framing, support for Medicare for All dropped significantly from the levels it reached when questions led with coverage and access outcomes.
That attack line no longer reliably moves the numbers.
A Data for Progress survey conducted in 2025 found that 63 percent of Americans support Medicare for All even when told it would eliminate most private insurance plans and require higher taxes. That is the hardest possible framing — the one PAHCF spent tens of millions of dollars making central to the public debate. It now produces majority support, including 64 percent of independents and 47 percent of Republicans.
The shift is not primarily the result of effective progressive messaging. It is the result of lived experience. Americans who have been denied prior authorization, received surprise bills, rationed medication, or lost coverage when they changed jobs have accumulated direct experiential evidence about what the current system actually delivers. The attack line that the existing system — with all its private insurance and its complexity — is preferable to a government-run alternative has become progressively harder to sustain as the existing system continues to deliver the experiences it delivers.
The PLOS study’s authors noted that PAHCF’s campaign was designed to increase doubt in the benefits of reform among people who had not yet formed a considered position on the issue. The forum — the deliberative space where considered positions get formed through engagement with evidence and with others’ experience — is specifically where the advertising campaign’s tools do not work. Persuasion by doubt operates on the unconsidered. It does not operate on the considered.
This is not a reason for confidence that reform will happen. It is a reason for precision about what the current moment represents. The information environment that PAHCF spent $60 million constructing is losing its structural advantage as the lived experience of the people it targeted diverges from the experience the advertising was designed to suggest. That divergence creates an opening. Openings close.
What the Historical Record Shows About Breaking Through
The series has referenced three historical cases in which the civic side developed a structural analysis, held it under sustained opposition, and produced outcomes that reflected the civic framing rather than the industry framing: tobacco regulation, leaded gasoline, and seat belt safety standards.
These cases are worth examining precisely because they involved organized industries applying versions of the same playbook PAHCF is running — manufacturing doubt, constructing surrogate opposition, working the legislative environment, and maintaining continuous pressure against reform over extended periods.
In each case, the decisive factor was not a single moment of public outrage or a single legislative champion. It was the accumulation of documented evidence held by organized constituencies over time periods that outlasted the industry’s capacity to sustain the appearance of legitimate uncertainty. The tobacco case took decades. Leaded gasoline took decades. Seat belt standards took decades. In each case, the turning point came when the gap between the industry’s manufactured narrative and the documented evidence became too large to sustain in the information environment — and when organized constituencies with preserved institutional memory and continuous presence were available to convert that gap into legislative action.
The civic side won those cases not by matching the industry’s financial resources but by building the kind of accumulated, preserved, continuously organized presence that the industry side had always maintained. The asymmetry of resources remained. The asymmetry of institutional memory and continuous presence was closed — not overnight, not in a single campaign cycle, but over the kind of long time horizon that the organized interests side had always operated on and that the civic side had rarely sustained.
The healthcare reform case has not followed that pattern yet. The evidence base is not the limiting factor — the documentation of what the current healthcare system costs, what it produces, and how it compares to systems in other countries is extensive, well-sourced, and broadly accessible. The limiting factor is the civic infrastructure that would allow that evidence to accumulate in organized form, connect the constituencies that have experienced the system’s failures, and maintain continuous presence in the legislative environment across the cycles that the organized interests side operates across without effort.
The Current Moment and What It Does Not Resolve
As of mid-2026, the landscape has shifted significantly from the period documented in Articles 1 through 5.
Medicare for All has 111 House co-sponsors — a majority of House Democrats, the highest share in the bill’s history. The Senate version carries 15 co-sponsors. The Fighting Oligarchy tour drew 261,000 people to events in 2025. Public support for Medicare for All has reached levels that survive the hardest available attack framing. The Republican budget cuts to Medicaid and the expiration of ACA subsidies have made healthcare costs a central issue for the 2026 midterm cycle, with Democrats holding a substantial trust advantage on the issue according to KFF polling.
PAHCF has no documented comparable public campaign in the current cycle. The coalition that spent $60 million in 2019 and 2020 is not visibly running the equivalent operation in 2025 and 2026. This is consistent with the operating model of a coalition that concentrates resources where the legislative threat is most immediate — and with a Republican-controlled House and Senate, the immediate federal legislative threat is low. The infrastructure does not disappear in low-threat periods. It waits.
What the current moment does not resolve is the structural question at the center of this series. The civic side is generating substantial episodic energy — large crowds, record fundraising, majority public support, growing legislative co-sponsorships. The organized interests side is running a reduced visible operation during a period of low immediate legislative threat. The conditions look favorable for reform in ways they have not looked for years.
Whether the civic side’s current energy accumulates into the kind of durable, preserved, continuously organized presence that produced outcomes in the tobacco, leaded gasoline, and seat belt cases — or whether it dissipates when the rally circuit ends, the midterm cycle concludes, and the organized interests side reactivates its full operational capacity when the legislative environment shifts — is the open question this series cannot answer.
It depends on what the civic side builds between now and the next time the PAHCF model is running at full scale.
What the Series Has Documented
Six articles. One coalition. Thirty years of strategic lineage. Sixty million dollars in two years. Dark money structure that conceals its funding by design. Democratic Party infrastructure hired to run the campaign against the Democratic Party’s most popular healthcare proposal. Surrogate networks of former Democratic officials carrying industry messaging without visible attribution. Ghostwritten op-eds published under legislators’ names and then cited as evidence of organic opposition. State-level operations that followed reform to Colorado and Connecticut and stripped the structural elements from legislation that remained. An advertising campaign of 40 million Facebook and Instagram views built on the same strategic playbook the tobacco industry used to manufacture doubt about smoking.
This is not a story about villains making unusual choices. It is a story about a structural arrangement — the continuous operations model, funded by concentrated financial interests, operating across decades and electoral cycles — doing exactly what it was designed to do. The people running PAHCF are professionals executing a documented strategy with a proven record. The legislators who adopted positions shaped by that strategy were operating in a political environment constructed by an institution with more continuous presence, more established relationships, and more accumulated institutional knowledge than any individual legislator or advocacy campaign could match.
The civic side’s task is not to find better arguments. The arguments are not the limiting factor. The civic side’s task is to build the infrastructure that converts the public’s genuine, majority, sustained support for healthcare reform into the kind of continuous organized presence that the organized interests side has always maintained and that has historically been the decisive factor in whether reform happens.
That infrastructure does not yet exist at the scale the problem requires. This series is part of documenting why it needs to.
How America’s Plan Addresses This
America’s Plan is designed to address the specific structural failures this series has documented — not all of them, not immediately, and not with certainty of outcome.
The Commons preserves what civic campaigns learn so the next effort does not rebuild from scratch — the Colorado documentation, the Connecticut record, the ghostwriting story, the consultant network analysis. The connective layer links organizations working on related problems so the knowledge that patient advocacy groups in Colorado generated is available to reform advocates in the next state before the fight begins rather than after it ends. The issue pipeline converts episodic civic energy into accumulating organizational capacity by moving from sentiment aggregation through plan development to sustained pressure and accountability tracking.
The honest assessment is that the platform is early-stage. It has not demonstrated outcomes that would justify stronger claims. What it has is a design that addresses the specific structural problem — the asymmetry between the continuous operations model and the campaign model — that this series has documented across six articles and thirty years of healthcare industry strategy.
The organized interests side proved this model works. They proved it on tobacco. They proved it on the Clinton healthcare plan. They proved it on the ACA public option. They proved it on Medicare for All. They proved it in Colorado and Connecticut.
The civic side is building the equivalent. The open question is not whether the model is viable — the organized interests side’s thirty-year record answers that. The open question is whether enough people engage with what is being built to make it consequential before the next time the PAHCF operation is running at full capacity and the window that currently exists has closed.
That question this series cannot answer. It depends on what happens next.
Sources: PLOS Global Public Health — Generating Opposition to Universal Health Care Policies in the United States, Kendra Chow et al., London School of Hygiene and Tropical Medicine (July 2025); EurekAlert — Private Health Industry Lobby Group Uses Marketing and Publicity Strategies Similar to Big Tobacco (July 2025); University of Edinburgh School of Social and Political Science — US Private Health Industry Lobby Group Uses Marketing and Publicity Strategies Similar to Big Tobacco (July 2025); Data for Progress — Medicare for All polling (2025); KFF — The Politics of Health Care and Elections (October 2025); Jacobin — Medicare for All Is an Electoral Winner (April 2026); CNN — Medicare for All Is Getting a Second Wind (April 2026); David Sirota — A Massive Shift in Health Care Politics (2025); GovTrack — S. 1506 Medicare for All Act 119th Congress (April 2025); Congress.gov — H.R. 3069 Medicare for All Act 119th Congress; FEC — Sanders and AOC Q1 2025 fundraising; Brookings — The Caregiving Crisis and the 2026 Vote (April 2026); americasplan.org — Capital Organizes. Why Don’t We? (Founder’s Column); americasplan.org — How Projects Like This One Fail.
The complete PAHCF Series
01 — What It Is and Why It Exists
02 — Who Funds It and What the Money Buys
03 — The Federal Strategy
06 — The Tobacco Playbook
The Organized Interests Playbook: A Structural Analysis of PAHCF
This article was researched and drafted with AI assistance under human review. See our full AI and editorial practices.