Interest Groups in Health Care Policy and Politics

Interest Groups in Health Care Policy and Politics

Joanne Rains Warner

“Politics isn’t about big money or power games; it’s about the improvement of people’s lives.”

—Paul Wellstone

A month before Barack Obama’s inauguration, health care interest groups had formed coalitions in order to urge the president-elect “to follow through on your campaign promise and commit to making healthcare and financial security reform a priority in the first 100 days of your administration.” This urgent plea signaled new possibilities of societal willingness to reform health (“Interest Groups,” 2008). Fast-forward 8 months when the health care reform efforts had intensified and President Obama was chiding special interest groups for “fighting to block his healthcare overhaul.” His strategy to engage special interests early and substantively was clearly a lesson learned from the failed reform efforts under President Bill Clinton (Espo, 2009). In the final analysis, the health reform efforts that history will record for President Obama will involve the robust influence of interest groups vociferously defending their stake and preferences in the structure and financing of the health care system.

Interest groups play a significant role in health care reform and any other issue. However, they are a paradox within our governing system. We need and value them; at the same time, they annoy and distract us. We embrace them as empowering opportunities for citizen involvement, and we resent their influence and perception of buying elections and votes. The love-hate ambivalence is born, in part, by the way a notion crafted in 1787 has translated into the technological, Washington-centric, mass communication political era of the twenty-first century. Democracy within the individualistic American society presents inherent tensions that are both our genius and our burden.

An interest group is a collection of people who pursue their common interests by influencing political processes. They are also known as factions, special interests, pressure groups, or organized interests. The original definition depicted them as “united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community” (Madison, 1787, paragraph 2). The mere act of organizing presupposes “some kind of political bias because organization is itself a mobilization of bias in preparation for action” (Schattschneider, 1960/2005, p. 279). Today, political arenas at the federal, state, and local levels experience the activity of organized groups who influence elections, votes, societal opinion, and the policy process itself.

This chapter gives context to the duality of distrust and appreciation for interest groups while also portraying them as a significant feature of our governing system. It traces the historical roots and development of interest groups, describes their functions and methods, and concludes that they embody the good, the bad, and the ugly of governance effectiveness. It also describes the contemporary terrain of health care interest groups, as well as a discernment framework for interest group involvement.

Development of Interest Groups

James Madison’s The Federalist No. 10 (1787) is part of his treatise on the preferred structure of a republic. He proposes that rather than removing the causes of factions, the best wisdom is to control the effects of interest groups. To do otherwise is to undermine liberty. The legitimate roots of interest-group organizing are therefore traced to the framers of the Constitution and the birth of the American version of democracy. Several decades later, the French philosopher and politician Alexis de Tocqueville traveled and observed this country from an outsider’s perspective. His Democracy in America (1835) endures as a classic description of our inclination to form associations for common purpose and to create a vibrant political structure independent of the state (de Tocqueville, 1835/2000).

The impetus to organize exists not only within the American people but also within the structure of our political system. The separation of powers and responsibilities in the federal system provides multiple points for exerting pressure on the policy process. Groups can influence outcomes through elections, work within each legislative chamber, executive branch pressure, and in the regulatory and implementation process at any level of government (Skocpol, 2003). This diffusion of power presents many opportunities for persuasion.

Historically, groups formed around interests such as abolition of slavery and prohibition of alcohol. At the turn of the twentieth century, the federal government and the associated bureaucracy blossomed, as did the presence of interest groups based in Washington. Business-oriented groups formed during the Progressive Legislative Era (early 1900s) and the New Deal Era (1930s). The social activism of the 1960s generated more groups focused on civil rights, the environment, and specific economic and humanitarian causes (Ness, 2000).

As the power and money of these groups grew, Congress acted to rein in their influence and limit direct contributions to candidates. However, the reforms that grew from the Watergate scandal of the 1970s inadvertently enhanced their power and diminished the leverage of political parties by promoting the formation of political action committees (PACs). Through PACs, the pooled money of many became more influential than that of a single donor. The Bipartisan Campaign Reform Act of 2002, also known as the McCain-Feingold Act, revised the Federal Election Campaign Act of 1971 to control “soft money” contributions—funds funneled through political parties to candidates or causes—and the funding of electioneering issues ads (Federal Election Commission, 2009a). Today, PACs who receive soft money have profound influence that society would like to curb but politicians seem to find advantageous. The politician’s resistance to change is also supported by a 1976 Supreme Court ruling (Buckley v. Valeo) that equated (unlimited) financial contributions as a constitutionally-protected form of free speech. For good or ill, money of special interests continues to grease our electoral, bureaucratic, and political wheels (Ness, 2000).

From the perspective of this historical development, several kinds of interest groups in existence today are evident: the older trade unions and business associations that protect and advance their economic interests, and the groups that tap the energy of newer social movements or contemporary issues (Fiorina, Peterson, Johnson, & Mayer, 2009). Within the latter group, there are consumer-focused interest groups that provide information and are especially active in the current health care reform debate. Examples include the U.S. Public Interest Research Groups (USPIRGs) who aspire to be the “advocate for the public interest” when special interest lobbyists threaten to dominate the dialogue, silence the voice of common citizens, and impede reform on issues of health, economy, and democracy (U.S. Public Interest Research Groups, 2009); Essential Action (a component of Essential Information), which provides information and wage campaigns on topics that are not visible in the mass media or on political agendas, including access to medicines and the global effort to reduce tobacco use (Essential Information, 2009); and the Center for Science in the Public Interest (CSPI), whose consumer advocacy in health and nutrition involve novel research, equipping citizens and policymakers with useful information, and ensuring that science and technology serve the public good (CSPI, 2009). These examples demonstrate the enduring nature of interest groups juxtaposed an evolving list of groups and issues.

When is a special interest group not what it appears? Astute citizens and policymakers need to be aware of “front groups” whose public persona is that of an unbiased, independent group but whose funds and agendas are from an industry or political party. Recent examples relate to health concerns. The Center for Consumer Freedom, whose message of individual choice is a front group for the restaurant, alcohol, and tobacco industries, opposes public health messages of science, health advocates, and environmental groups calling them a “growing fraternity of food cops, health care enforcers, anti-meat activists, and meddling bureaucrats who ‘know what’s best for you’” (Source Watch, 2009). Contributions Watch is a public relations front group masquerading as a public interest campaign reform group; their agenda is to smear and discredit their political enemies, and their funding has been revealed as entirely from the tobacco-and-food conglomerate Philip Morris (Stauber & Rampton, 2004). The popular “Get Government Off Our Back” (GGOOB) campaign was also exposed as a tobacco industry front group that rallied diverse groups to oppose policy. Analysis of GGOOB suggests that knowing a group’s history and funding can limit the harmful effects of misrepresentation and highlights how ideologic arguments can diminish the power of solid science and research findings in policymaking (Apolionio & Bero, 2007). The presence of front groups calls each information consumer—citizen and policymaker—to a vigilance about the bias and intention of groups who advocate and provide information.

Functions and Methods of Influence

How do interest groups function within our complicated governance system? What operating methods can they use to advance their causes, and how do they determine which to use? Their methods include lobbying, grassroots mobilization, influencing elections, shaping public opinion, direct action, and litigation.


Lobbying involves the direct influence of public officials and ultimately an influence on their decisions or legislation. Wolpe (1990) presented a concise description of lobbying as “the political management of information” (p. 9) because it involves educating, shaping opinions, and offering research, data, and analyses. Lobbyists also often assist in bill drafting and revision. By hiring full-time Washington- or state-based lobbyists, groups have a more enduring presence in the legislative processes; this also allows ongoing relationships between staff, officials, and lobbyists to become the foundation of influence. Lobbyists become adept at the nuances of the legislative process and provide nimble responses.

The number of federal lobbyists increased from 10,661 in 1998 to 14,838 in 2008, and the total lobbying spending costs during the same period increased from $1.44 billion to $3.30 billion (Center for Responsive Politics, 2009a). Of the top 20 lobbying industries in 2009, 5 are related to health causes: pharmaceutical/health products, insurance, hospitals/nursing homes, health professionals, and health services/HMOs, in order of size (Center for Responsive Politics, 2009b). Lobbying is thus a substantial business.

Grassroots Mobilization

Grassroots mobilization involves indirectly influencing officials through constituency contact. More decentralized politics and expanded options in technology and communication make grassroots involvement effective and popular. Pseudo-grassroots efforts that mobilize technology more than citizens are mockingly called astroturf lobbying; another version is grass-tops lobbying, when a prominent personality is used to champion an issue through ads or letters. Most interest groups employ some version of grassroots mobilization.

Grassroots lobbying is effective for several reasons. It signals to officials that an issue is significant enough to prompt citizen action. It indicates that citizens can be mobilized to support this issue (which might also be true for the official’s next election!). Lastly, it strengthens the communication and accountability between the legislator and the citizens; both realize the other is following their activities (Bergan, 2009).

Electoral Influence

Electoral influence can be considered the “primary prevention” of policymaking because it is important activity that precedes policy work. It determines who is elected to the policymaking table in the first place to debate and shape future policies (Warner, 2002). Successful electoral campaigns need three resources: time, money, and people; interest groups can provide the last two. PACs are the primary vehicles for raising and donating money to the elections of individuals determined to match the interests and values of the group. Just as interest groups provide a collective voice, PACs provide the collective financial support. For example, the American Nurses Association (ANA) formed the ANA-PAC in 1974 to support candidates for federal office who match the ANA agenda and values, with the ultimate intent of improving the health care system (ANA, 2009). Through campaign reform efforts in 2002, the influence of PACs has been contained. PACs can only give $5000 per election (primary, general, or special) and $15,000 annually to a national party, while individuals can give up to $4800 per year to each candidate who runs in both a primary and general election (Federal Election Commission, 2009b).

Shaping Public Opinion

Shaping public opinion overlaps with electoral influence and grassroots mobilization; it involves issue advocacy and public persuasion, similar to campaigning for an issue. Think of it as an infomercial that sells an issue or as direct mail tactics that use paper or technology to blanket an area with a perspective. Think of the ways the impression of societal consensus or preference could, in turn, persuade policymakers as they vote and create policy. Most of these initiatives cost money, but occasionally groups obtain “free” media coverage in the form of news coverage.

Interest groups can also employ direct action to accomplish their goals with visibility and drama. Examples include peaceful demonstrations, boycotts, marches, riots, or violent acts. Groups representing social causes and contemporary issues employ direct action more often than professional or trade groups. Media coverage for these events is a desired strategy to reach larger audiences.


Lastly, litigation provides another method to shape governance toward the goals of the group. The Brown v. Board of Education of Topeka, Kansas is a classic example of years of strategic effort culminating in a significant judicial ruling changing the landscape of society. The National Association for the Advancement of Colored People (NAACP) was the interest group championing social justice and the elimination of racial discrimination who organized 200 plaintiffs in 5 states to bring cases of racial segregation and discrimination in schools to the Supreme Court. Rippling beyond application to education, this ruling affected racial discrimination throughout society, and it inspired interest groups to pursue their proposed change through the court system (Brown Foundation for Educational Equity, Excellence and Research, 2004).

Given the menu of methods discussed in this chapter, how do interest groups create their action plans? Victor (2001) suggested that they make three decisions. First, they determine whether their efforts are individual or orchestrated in coalition with other groups. Coalition work provides the advantages of pooled resources within a complex process, but it involves coordination, negotiation, and potential compromise. Second, they consider at which stage of the legislative process to focus their efforts (e.g., societal agenda setting, committee, full chamber, or regulatory process). Finally, a choice of tactics is necessary. This choice hinges on the group’s resources, various contextual characteristics (for example, which political party is in control), and whether there is more concern for legislative detail or general ideologic posturing (Fiorina et al., 2009).

Each interest group, therefore, develops a distinct identity that originates in its choices, resources, and purpose. This discussion of function and method illustrates that their influence within the governance process, whether nuanced or bold, can span the entire process and can range from superficial to substantial.

Related to the scope of influence of interest groups is the question of their effectiveness. The critique ranges from the good to the bad and the ugly. Many maintain that they successfully enhance our democratic processes with varied inputs. Those who defend the value and influence of groups maintain that they “fulfill some of America’s earliest and most enduring political ideals” (Ness, 2000, p. xx [preface]), as argued by James Madison. In doing so, they prevent violence and tyranny in society by engaging citizens in social change through other means. In theory, groups represent our pluralistic and transparent mode of government. In practice, scholars believe that their influence is often cancelled out by the opposing groups lobbying, media, or actions (Fiorina et al., 2009).

The bad and the ugly of their influence were termed demosclerosis or the clogged vessels of our governmental body and subsequent policy gridlock. This acknowledges that the maximum well-being of the country cannot be achieved through the collective concerns of special interests, and that we grind into inaction with too much attention to special groups vying for their own advantage (Rauch, 1994). Quadagno (2005) presents a bold, relevant example of demosclerosis by concluding that health care reform has been thwarted by special interests over the years and that these groups are the “primary impediment to national health insurance” (p. 207). Even as the anti-reform coalition has changed over the years from primarily physicians to insurers, its goal of inertia and status quo has prevailed over the reformers’ efforts.

Landscape of Contemporary Health Care Interest Groups

A Pittsburg Post-Gazette editorial warned President-Elect Obama against health care reform early in his presidency because “the field is a rat’s nest of entrenched interests” (Pittsburgh Post-Gazette, 2008, p. 2). This unsavory reference underscores the complex, historic, and dominant nature of health care interests. Who are these players, what money is involved, and what is nursing’s place and relative effectiveness in the context of federal lobbying groups?

The Center for Responsive Politics (a non-partisan, non-profit research group that tracks money in politics) includes five categories in the health industry sector: health professionals, health services/health maintenance organizations, hospitals/nursing homes, pharmaceuticals/health products, and miscellaneous health concerns. Funds from interest groups are predominantly spent on lobbying and on campaign contributions, and the health industry is heavily involved in both. The health sector ranked first in money spent in 2008 lobbying: $485 million and 3562 lobbyists reported (Center for Responsive Politics, 2008). And, as noted earlier in the chapter, among the list of Top 20 lobbying industries in 2009, 5 relate to health care. In the 2008 federal election, 127 health-related PACs contributed over $49 million to influence elections. Significant influence and money are also organized through health interest groups (Center for Responsive Politics, 2008).

The list of stakeholders concerned with health care reform also includes those outside the health industry (e.g., insurance corporations, labor unions, chambers of commerce, and a host of business and consumer groups such as the American Association of Retired Persons). In fact, from an ecological perspective, few topics do not eventually trace back to health and the human potential it impacts.

Table 81-1 presents trended amounts of campaign contributions made by health professionals from 1990 to 2008. This includes both PACs of health professionals and individual contributions. It demonstrates dramatic increases in campaign contributions and variation in the partisan allocations, usually related to which party is in power. Clearly, health professionals are engaged in electoral politics.

Mar 18, 2017 | Posted by in NURSING | Comments Off on Interest Groups in Health Care Policy and Politics

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