Health care lobbying in the United States
Article Outline
Abstract
Purpose
To assess the relative political influence of different organizations, we examined the efforts of health care organizations to influence policy decisions by lobbying lawmakers.
Methods
We reviewed reports filed by lobbyists from 1997 to 2000, as required by the Lobbying Disclosure Act, to characterize health care lobbying at the federal level in the United States.
Results
Health care lobbying expenditures totaled $237 million in 2000. These expenditures accounted for 15% of all federal lobbying and were larger than the lobbying expenditures of every other sector, including agriculture, communications, and defense. A total of 1192 organizations were involved in health care lobbying. Pharmaceutical and health product companies spent the most ($96 million), followed by physicians and other health professionals ($46 million). Disease advocacy and public health organizations spent $12 million. From 1997 to 2000, lobbying expenditures by physicians and other health professionals grew more slowly than lobbying by other organizations (10% vs. 26%).
Conclusion
Although policy decisions are influenced by many factors, our findings may indicate a limited political influence of disease advocacy and public health organizations and a declining political influence of physicians and other health professionals.
Health care organizations lobby lawmakers to influence health policy decisions, which affect virtually all aspects of health care, including compensation for goods and services, licensing and oversight, and research priorities 1, 2, 3. In a previous investigation, we described lobbying activities by individual physicians (4); however, little is known about the lobbying activities of health care organizations, such as medical associations, public health groups, and health-related businesses. Future efforts to use legislation to improve patient care and public health may be aided by a better understanding of health care lobbying.
The 1995 Lobbying Disclosure Act provides a unique opportunity to study lobbying at the federal level, including Congress, the White House, and federal agencies. The law requires lobbyists to submit biannual reports describing the organization for which they lobbied and the amount spent on lobbying activities (5). We took advantage of this act to examine health care lobbying expenditures and the number and type of organizations involved in lobbying to determine their relative political influence.
Methods
Because of the difficulty involved in manually reviewing the more than 40,000 lobbying reports filed each year, to focus our review we used data from the Center for Responsive Politics (6), a nonpartisan, nonprofit research group that classifies lobbying reports into approximately 100 areas based on the organization involved (7). We focused on lobbying activities from 1997 to 2000 in 12 areas likely to contain health-related organizations: education, health professionals, health maintenance organizations and managed care, health services, hospitals and nursing homes, human rights, insurance, miscellaneous health, pharmaceutical and medical supply, nonprofit, other, and women's issues. We identified all health-related organizations and classified them into one of five major categories: pharmaceutical and health product companies, physicians and other health professionals, hospitals and nursing homes, health insurance and managed care companies, and disease advocacy and public health organizations. If necessary, we obtained additional information from an organization to properly categorize it. We used aggregate data from the Center for Responsive Politics to estimate lobbying expenditures in other sectors, such as agriculture, communications, and defense.
Results
Lobbying expenditures
Health care lobbying expenditures totaled $237 million in 2000. Health care lobbying expenditures accounted for 15% of all federal lobbying and were larger than the expenditures of every other sector, including agriculture ($78 million), communications ($201 million), defense ($60 million), energy and natural resources ($159 million), finance ($229 million), ideological and single-issue lobbying ($85 million), miscellaneous business ($224 million), other ($169 million), and transportation ($138 million). From 1997 to 2000, total health care lobbying expenditures increased by 26% and nonhealth lobbying expenditures increased by 27%.
Number of organizations involved
In 2000, a total of 1192 organizations were involved in health care lobbying. From 1997 to 2000, the number of organizations increased by 50%.
Expenditures by type of organizations
In 2000, pharmaceutical and health product companies spent the most on lobbying ($96 million) followed by physicians and other health professionals ($46 million), hospitals and nursing homes ($40 million), health insurance and managed care companies ($31 million), and disease advocacy and public health organizations ($12 million) (Table). The largest components of spending by pharmaceutical and health product companies came from pharmaceutical manufacturers ($74 million) and medical supply companies ($14 million). The largest components of spending by physicians and other health professionals came from physician associations ($35 million) and nursing associations ($4 million).
Table. Lobbying Expenditures in 2000, by Organization
| Organization* | Expenditures ($ in millions) |
|---|---|
| Pharmaceutical and health product companies | |
| Pharmaceutical Research & Manufacturers of America | 7.5 |
| Schering Corporation | 7.3 |
| Eli Lilly & Company | 5.3 |
| Abbott Laboratories | 4.8 |
| Bristol-Myers Squibb | 4.7 |
| American Home Products | 4.0 |
| Advanced Medical Technology Association | 3.9 |
| Pharmacia Corporation | 3.8 |
| Pfizer Incorporated | 3.4 |
| Glaxo Wellcome Incorporated | 3.1 |
| Physicians and other health professionals | |
| American Medical Association | 16.6 |
| American Society of Anesthesiologists | 4.3 |
| American Association of Nurse Anesthetists | 2.6 |
| American College of Physicians | 2.1 |
| American Academy of Family Physicians | 1.6 |
| American Psychological Association | 0.9 |
| College of American Pathologists | 0.9 |
| American Optometric Association | 0.8 |
| American Academy of Ophthalmology | 0.8 |
| American Physical Therapy Association | 0.7 |
| Hospitals and nursing homes | |
| American Hospital Association | 10.4 |
| Federation of American Hospitals | 1.9 |
| University of Pittsburgh Medical Center | 1.2 |
| Manor Care Incorporated | 0.9 |
| Healthcare Association of New York | 0.9 |
| Alliance for Quality Nursing Home Care | 0.6 |
| American Health Care Association | 0.6 |
| National Association for Home Care Plus Incorporated | 0.6 |
| Government Employee Hospital Association | 0.6 |
| Premier Incorporated | 0.5 |
| Health insurance and managed care companies | |
| Health Insurance Association of America | 6.9 |
| Blue Cross/Blue Shield | 6.3 |
| American Association of Health Plans | 3.6 |
| State Farm Insurance | 1.7 |
| AFLAC Incorporated | 1.6 |
| Cigna Corporation | 1.6 |
| Aetna Incorporated | 1.6 |
| United HealthCare Corporation | 1.1 |
| PacifiCare Health Systems | 0.7 |
| Kaiser Foundation Health Plan | 0.5 |
| Disease advocacy and public health organizations | |
| American Cancer Society | 0.5 |
| American Heart Association | 0.5 |
| American Foundation for AIDS Research | 0.5 |
| Memorial Sloan-Kettering Cancer Center | 0.5 |
| March of Dimes Birth Defects Foundation | 0.5 |
| National Association of Community Health Centers | 0.4 |
| Patient Access to Transplantation Coalition | 0.4 |
| Disabled American Veterans | 0.4 |
| Cities Advocating Emergency AIDS Relief | 0.4 |
| National Center for Tobacco Free Kids | 0.3 |
* Top 10 spenders in each category |
Approximately $12 million was spent on health care lobbying by organizations that did not fit into one of the five categories above. The specific organizations with the highest expenditures include the Healthcare Leadership Council, a coalition that promotes market-based solutions to health policy problems ($1 million); the Association of American Medical Colleges ($0.6 million); the American Clinical Lab Association ($0.6 million); and Physician Insurers of America, a trade association of malpractice insurance companies ($0.6 million).
Changes over time
From 1997 to 2000, lobbying expenditures by pharmaceutical/health product companies grew by 27%, expenditures by physicians/health professionals grew by 10%, expenditures by hospitals/nursing homes grew by 59%, expenditures by health insurance/managed care companies grew by 14%, and expenditures by disease advocacy/public health organizations grew by 9% (Figure). The rate of increase in expenditures was significantly greater (P <0.05) among pharmaceutical/health product companies and hospitals/nursing homes compared with other organizations.
Figure.
Trends in health lobbying expenditures by different types of groups from 1997 to 2000 The rate of increase in expenditures was significantly greater (P <0.05) among pharmaceutical/health product companies and hospitals/nursing homes (solid lines) compared with other organizations (dotted lines).
Discussion
This study takes advantage of the Lobbying Disclosure Act, which requires lobbyists to report on their lobbying activates, to examine comprehensively all health care lobbying at the federal level in the United States. The substantial amounts spent on health care lobbying highlight the importance of health care issues to a broad range of interest groups. Although health policy decisions are influenced by many factors (e.g., political alliances, campaign contributions, research findings), the high lobbying expenditures of pharmaceutical and health product companies may indicate that they are better able to convey their perspective to legislators. By contrast, disease advocacy and public health organizations spend relatively little on lobbying and may have less influence as a result. Physicians and other health professionals also spend a great deal on lobbying, but their political influence may decline if their spending growth continues to lag behind that of other organizations.
Although disease advocacy and public health organizations have long had meager resources, it is unclear what factors have limited the growth of spending by physicians and other health professionals. The input of both types of organization is essential at a time of growing concern and debate about the cost of prescription drugs, the influence of pharmaceutical marketing on patients and physicians, access to health care for the uninsured, declining Medicare reimbursement, and medical research priorities 8, 9, 10, 11. In a previous investigation, it was shown that legislators specifically request increased input from constituents on these types of health issues (4).
Several limitations should be considered in interpreting our findings. First, because the Lobbying Disclosure Act only requires reporting to the nearest $20,000, there is some imprecision in our calculations. In addition, organizations that spend less than $20,000 are not required to file reports. Second, lobbying reports do not specify the legislation discussed or the positions advocated by lobbyists. As a result, we could not determine the effect of lobbying expenditures on the attitudes of the people who ultimately make health policy decisions. Third, we did not have information on the relative distribution of various components of lobbying expenditures, such as salaries, printing costs, transportation expenses, and meals, nor did we have data on the proportion of each organization's budget devoted to lobbying. Fourth, all organizations within a category are unlikely to have the same interests. For example, teaching and nonteaching hospitals may have opposing perspectives on Medicare funding of residents. Fifth, we were unable to examine health care lobbying at the state and local level. We also did not examine other influences on policy decisions, such as campaign contributions or policy-relevant research findings 12, 13, 14. Sixth, it is possible that specific health care issues being considered at a particular time influenced lobbying expenditures by certain organizations.
Conclusion
There are sizeable disparities in the health care lobbying expenditures of various interest groups. Health advocacy groups may need to consider the relative distribution of these expenditures as they formulate legislative strategies. In addition, requiring more detailed reporting, including specifying the legislation discussed and the positions advocated by lobbyists, could strengthen the Lobbying Disclosure Act.
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PII: S0002-9343(03)00803-9
doi:10.1016/j.amjmed.2003.10.037
© 2004 Excerpta Medica Inc. All rights reserved.
