For better or worse, special interest groups drive the American political system on the local, state, and national levels. The reason for this is both simple and complex. Interest groups generate campaign dollars and highly motivated volunteers. Politicians cannot change things unless they get elected, and to get elected, they need people and money. Less visible to the public, the special interest groups also form a brain trust that breeds – and funds the development of – innovative ideas that have the potential to become the basis for new policy initiates, both good and bad from the taxpayer’s standpoint.

There are as many special interest groups as there are issues to debate. These issues include mental health, pharmaceuticals, physicians, hospitals, Long Term Care (LTC), the elderly, the indigent, rural health participants, STD/AIDS, universal health care, and so forth.
Each of these categories has sub-groups that have even more defined interests that may differ from the broader group. For instance, the Federation of American Healthcare Systems (FAH) is the trade group representing only for-profit hospitals. Driven by publicly held firms, it is not nearly as concerned with trustee issues as is the American Hospital Association (AHA), which theoretically represents the entire industry but in reality consists primarily of non-profit facilities, which are responsible to boards of local trustees.
How do these groups operate? If they follow traditional procedures, they meet with legislators to discuss a particular bill or issue, often providing “perks” such as free meals or tickets to special events. Primarily, they seek to convince politicians that they represent a significant constituency since politicians are rarely interested in passing a bill that pleases only a few people. Because this fast-paced age has produced thousands of groups and individuals constantly try to influence legislators, however, special interest groups have found that they must continuously change their tactics. The McCain Bill (cigarette tax increase) opposition effort is a good example of this fact. According to Stoil (1998),
The core of traditional lobbying has always been gaining the undivided attention of hardpressed legislators to listen to an industry’s or interest group’s position. Professional organizations employ staffs of “legislative representatives” whose job it is to gain access to tightly scheduled congressmen and their aides and present their organizational positions. Offers of speaking engagements, invitations to parties and Capitol Hill receptions, and (for the more well-heeled) arrangements of special trips had long been the stock-in-trade of the Washington lobbyists. That is, until 1995, when changes in ethics rules and Congress’s own self-imposed schedules devalued many of these tools . . . [S]o, what was the “new lobbying”[?] . . . basically, it focused on mobilizing constituent anger in states where a Senator or Representative faced a serious challenge. At least $40 million was spent on broadcast, billboard and print advertising, as well as telephone calls and targeted mailings, to show Congress that constituents strongly opposed the cigarette tax increase. (p. 8)
Lobbying is a complex task. Some members of the public assume that the process is fraught with direct pay-offs, greed, and self-interest. In a few isolated cases, this may be true.
However, the political process is generally much more complicated than that and, in my experience as a local elected official, most politicians like to think that they are fighting the good fight, even if they have to talk themselves into believing that premise by twisting the facts.
The fact is that most people, including lobbyists, believe that what they are fighting for is right. They see issues from the vantage point of their organization and their lives. For example, those who lobby for expanded Medicaid benefits are either on, or have been on, Medicaid or, more likely, make a living by working with those on Medicaid. As a result, they see the needs of
Medicaid recipients, while they may not see the needs of other groups who are also lobbying for increased funds. Because of their focus and desire to influence, they use whatever means they find to get what they want. Since individuals have little clout – the government cannot make laws based on the needs of one person – those who want to influence government find that they need an organization. Then they find that their organization needs money and employees who are experts in certain fields so that legislators will respect their opinions. What may have begun as a simple process propelled by one or two people becomes a national lobby as individual groups grow and connect or as certain industries find that they need to fund a trade organization to make sure that their voices are heard. Labor unions, for example, are some of the most powerful lobbies in the nation. As Bigelow (1997) states:
Organizations have several strategies available to exert control over the legislative environment…they include the use of expert witnesses, personal visits to legislators, and technical reports. However, while information strategies may be used by individual organizations, collective action is often necessary, especially at the national level, for two reasons. First, legislators are not likely to be influenced by individual voices unless they represent a considerable constituency. Second, successful strategies require an intimate knowledge of the public policy and legislative processes. While occasional managers may have both the constituency and the knowledge, both are more likely to reside in industry associations. At this stage what Buchholz terms political strategies – lobbying, political action committee (PAC) contributions, and the use of trade associations – dominate. (p. 53)
Doctors make more than 29,000 visits, primarily regarding reimbursement and managed care reform, to Congressional aids each year. This direct contact, combined with the esteem in which the profession is held and the dollars given by medical associations, creates formidable clout. In a Wall Street Journal article, Cummings (2003) gives an example of how the American
Medical Association influences national politics:
With its top legislative priority on the line, the AMA has moved all its leadership meetings in 2003 to Washington, giving the doctors who attend plenty of opportunity to lobby their representatives. “We are going to take every opportunity to visit the House and Senate to convince those who haven’t been in favor and thank those who have been,” says Dr. Palmisano. (p. A4)
Health care in the United States is big business, one of the largest in fact. Bigelow (1997) further explains the far-sighted and sophisticated nature of the health care lobbying efforts of United States corporations:
Corporate political strategy, however, encompasses not only activities employed in response to regulation but those designed to anticipate and influence it as well. For example, in addition to responding to regulation, organizations engage in goodwill strategies such as community outreach and education in anticipation of averting issues or garnering support in the future, and in a variety of communication and political strategies to influence issues before they become formalized as legislation. Indeed, organizations that wait for issues to become formalized before taking action have lost considerable discretion because at that point managers’ decision-making power is greatly reduced. (p. 53)
Going back to the for-profit hospital example given earlier, a personal experience comes to mind. In the 1980s, one particular state developed a strategic facilities plan by which a few very large non-profit tertiary institutions would essentially be the focal point of care, obtaining governmental regulatory approvals for sophisticated services as part of a tiered system of care.
This action would have negative financial implications for the mid-sized for-profits. As manager of planning and development for a hospital company with numerous facilities in that state, I was charged with stopping the approval and signing of the State Health Plan by the governor.
Compared to the well-connected and funded non-profits, my resources were limited: I had a small budget, few personal political contacts, and no assignable staff. But I succeeded in having the governor turn back the plan for revision. How?
1. By establishing a clearly defined goal very early on, well ahead of the competition.
That goal was to stop the signing until the offending portion was deleted.
2. By creating a specific broad-based coalition strategy: hospital trustees and physicians from all for-profit hospitals in the state met with and influenced decision makers.
3. By establishing a written action plan to achieve these objectives.
The non-profit competition was still analyzing the issue while the for-profit hospitals had hundreds of well respected local people, such as bankers, lawyers and physicians, going to the capitol and meeting with key legislators, many of whom were their personal friends.
Other organizations have had similar experiences; a clear strategy and well-defined action plan creates results. For example, the mental health lobby was able to include mental health benefits in the Clinton Reform Plan. Koyanagi (1995) says, “The main lesson of the 1993-
1994 debate is that political organizing, built on a solid foundation of research and treatment experience, can overcome apathy, fear, and stigma – the three major adversaries of nondiscriminatory mental health coverage” (p. 124).
The pharmaceutical industry, which has been particularly effective in its efforts over the years to protect its profitability, places lobbying as a top priority. I know one chief lobbyist who is both a M.D. and an attorney. With experience in both medicine and law, he was in a unique position to understand and discuss legislation affecting health care. One interesting article in the
Journal Record (2004) detailed one of the industry’s more innovative efforts regarding a hairstylist and supposed consumer advocate, a Ms. Helms:
Elizabeth Helms arrived on Capitol Hill on a warm Tuesday afternoon in July with a simple message for Congress: drugstores, not drug makers, are to blame for the high cost of prescription medicines. . . . What her audience did not hear, however, is that she also works full time for a public relations company whose clients include the Pharmaceutical
Research and Manufacturers of America, the drug industry’s trade group. (p. 1)
A 2004 column in the Atlanta Journal Constitution by Rost (2004), a vice president of marketing for Pfizer, one of the largest pharmaceutical firms in the world, shed more light on the situation. He indicated that in other countries drug prices are “35% to 55% lower than in the United States” (p. 13). He further stated that 28% of uninsured adults went without medications in 2000 due to the cost and attributes the situation to the drug industry’s successful efforts to block reform initiatives such as re-importation and group purchasing, which lower profits and, according to researchers, diminish funds that allow pharmaceutical companies to develop new drugs. According to Marchione (2004), the private sector now funds two-thirds of medical research (p. B1). Ron Pollack, executive director of Families USA, a liberal advocacy group that wants Congress to pass a more-generous drug benefit, adds, “It’s an industry pattern. Different parts of the industry try to get their piece of the gravy train” (McGinely & Lueck, 2003, p. A4).
Another example of special interests influencing the political process is the nursing home industry. Many LTC experts are firmly convinced that the best use of our dollars is to provide non-institutional care that permits the senior citizen to remain within his or her home. However, according to Weiner (1998), our public monies are largely going to nursing homes:
The for-profit nursing home industry is viewed as the strongest health lobby on Medicaid issues in all of the (studied) states. This influence derives from several sources. First, nursing homes are far more focused on Medicaid and state policy than are other provider groups. Comparatively, nursing homes are much more dependent on Medicaid revenue than hospitals or physicians are. Second, because nursing homes are so focused on state policy, they meet frequently with state a official, which increases the level of personal acquaintance and friendship. Third, the industry is large and well financed enough to afford highly paid lobbyists and can commission studies to support its positions. Finally, nursing homes are frequent and large contributors to the political campaigns of governors and state legislators. (p. 81)
There have also been consumer led special interest efforts, although the data is mixed as to what effect they have had on the broader national health system. Hoffman (2003) says,
These types of activism have ostensibly focused on a single issue (such as abortion or desegregation) or on demanding benefits for one particular group (such as AIDS patients or the disabled). The reforms they advocated, and in many cases won, made important changes in the health care system but arguably, did not alter the nature of the system itself. A recurring theme of health care activist movements has been the broadening of their single-issue and particular demands to include fundamental change in the U.S. health care system. (p. 79)
In summary, then, the role of special interest groups is entrenched within our form of government. They serve a unique purpose, if not always the interests of the consumer or voter.
As George Mitchell, former Senate Majority Leader, once told me, special interest group funding is one of the major problems in American political life today, but there seems to be no perfect solution. Democracy – including interest group politics – is not perfect, but it is still the best system of government.