Lobbying Mediocrity

Prior to becoming a physician, I worked as a legislative assistant on Capitol Hill. Most of my 4 years in Congress was spent working for a member of the House Committee on Commerce, an authorizing committee for health policy. Capitol Hill tends to attract young, well-educated individuals who are woefully inexperienced relative to their responsibilities and influence. I was no exception. I was 22, idealistic and knew just enough about public policy to get myself into a great deal of trouble. I can recall my first meeting with a high-powered lobbyist. He accompanied three CEOs from our Congressional District. You can imagine the look on his face when I told him that my boss was “unavoidably detained” and I would meet with them instead. I remember thinking how these gentlemen all stepped onto private jets that morning to fly 2,000 miles to Washington, DC. In contrast, I walked to work that morning. I was 23 years old but looked 17. I didn’t even own a bike. I currently work in a busy, academic emergency department and truly enjoy my job. I admit, however, there is unpleasant irony associated with witnessing the legislative failures of my previous career on a daily basis. Patients in my department would not need emergency medical care if simple preventative measures, such as glycemic and blood pressure control, were fundamental goals of health care programs. Other patients, many of them with health insurance, simply cannot afford the deductibles and costs associated with outpatient care. Yet the failure of Congress to understand our health care system does not trouble me as much as the failure of physicians to understand our political system. Physicians commonly argue that they do not have time to meet with their elected officials or that our nation’s political system is too complex to navigate. Other physicians express outright disdain for our political process. They often say that lobbying is a waste of time because politicians are corrupt or do not listen. For those physicians who find time to participate politically, many of them are uncertain about what it takes to effectively advocate for legislative change. For example, many physicians consider themselves politically “active” if they write a campaign check or attend a public policy conference in Washington, DC, once a year. These physicians also tend to believe that our day-to-day lobbying is being well-handled by groups such as the American Medical Association (AMA) or perhaps one of the many subspecialty trade groups in Washington. My personal experience with physicians is that we, both individually in terms of our grassroots activities and collectively as a special interest, are mediocre lobbyists and are significantly less influential than other key stakeholders in the health industry. Whereas for much of the post–World War II era physicians enjoyed a virtual “monopoly” in health politics, today physicians barely seem to care about shaping public policy.1, 2 When it comes to lobbying, physician lobbyists seem to accomplish the least with the most. We have money and other political resources. As recent as the 1980s, the AMA was ranked by Laumann and Knoke as the most influential health “organization” in the nation.3 But by 2003, the AMA’s political influence was ranked inferior to both the American Association for Retired Persons (AARP) and the Pharmaceutical Research and Manufacturers of America (PhRMA).4 From the perspective of someone who has met with over a thousand lobbyists while working in Washington, DC, I can tell you that physician problems with public policy advocacy are numerous and complex. Our biggest problems, however, are that our political attendance is poor, our lobbying strategies are outdated, and we are overly apathetic and negative about the political process. If you talk with Congressional staffers, they will tell you that one of the main struggles for physicians in Washington is actually attracting physicians to Washington. I recall telephoning physicians back in my boss’s district to ask if they would travel to DC to speak on an important health care technology initiative. Not one physician or physician lobbyist returned my call. The next morning I received phone calls from three health insurance company employees from our district who learned, independent of my phone calls, about my boss’s interest on the subject. That afternoon, I received a phone call from a lobbyist from a major drug company. He was arranging flights for three company employees with expertise on the issue to fly to Washington to meet in our office. The best lobbyists utilize (among other things) special interest tactics (i.e., high-level meetings with CEOs and members of Congress) and grassroots tools (i.e., mobilizing constituent employees to contact elected officials) to advance their legislative agenda. Drug company lobbyists have perfected this art. They walk the halls of Congress nearly every day and understand the day-to-day, crisis-driven needs of members of Congress and staff. They provide easily understandable educational materials, fly in witnesses to testify at congressional hearings and are capable of rapidly mobilizing their workforces to contact or visit members’ offices who support (or oppose) their legislation. Drug company lobbyists also have good timing. Instead of showing up during times of crisis to ask for a legislative “fix,” drug company lobbyists visit decision-makers when the legislative calendar is slow and members are more accessible to talk. They also brilliantly ask members of Congress what they can do to help, as opposed to just asking for help. It is true that drug companies are known for lavish receptions and dinners, but it is their personal, day-to-day attendance and the relationships they cultivate with lawmakers that bolster their legislative influence. Physicians often complain that we cannot compete with drug companies in terms of political spending, yet it was the AMA, not Pfizer or Merck, who contributed more political action committee (PAC) dollars in 2006. In fact, health professionals gave 40% more to candidates than the pharmaceutical and medical device industry and 72% more than the hospital industry in 2006.5 Thus, it’s not that physicians lack political dollars. We simply choose to spend more on campaigns and less on lobbying. Between 1998 and 2006, for example, total lobbying expenditures in the health industry increased approximately 7% per year. During the same period, health professionals increased their lobbying expenditures about 3% per year. Overall, between 1998 and 2006, the pharmaceutical and medical device companies spent approximately 57% more on lobbying than physicians.6 The spending strategy emphasized by physicians would not be controversial if it were successful, yet evidence exists to the contrary. The most recent legislative accomplishment for physicians, for example, occurred late last year when Congress passed S. 2499, The Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173). This bill, successfully lobbied by the AMA, extends by 6 months mandatory cuts to Medicare physician reimbursement. Unless new legislation is passed by July 1, 2008, 10% across-the-board cuts will take effect.7 Contrast this with the legislative accomplishments of the drug industry over the past decade. During debate on the Medicare Modernization Act of 2003, for example, the drug companies helped pass a lucrative provision that prohibited the federal government from negotiating reduced prices for prescription drugs covered by Medicare.8 Drug companies have also been successful at passing federal tax credits that help them protect foreign earnings, as well as blocking legislation to permit the importation of cheaper drugs from Canada.9 Their legislative success has resulted in billion-dollar windfalls to the industry. To clarify, no one is arguing that physicians are politically weak. The AMA continues to be a major broker in health policy and physicians have been identified as trustworthy sources for political advocacy.10 In addition, no one is suggesting that campaign spending is a waste of money or that somehow physicians would recapture their political fortunes if we were to spend all of our money on lobbying. Every good Congressional staff member knows that the best political advocates do both. They give to campaigns and they lobby relentlessly. Most physicians say that they do not have time to meet with their elected officials. Still others are dubious and skeptical about hiring expensive lobbying and public relations firms to manage physician advocacy. Others say that meeting with officials is a waste of time because our political system is corrupt and politicians do not listen. I really do not know what to tell physicians who claim politics is “dirty.” While I agree that it can be dirty, our nation’s political process is no more petty than hospital board rooms and physician-run administrative committees. In addition, the same physicians who argue politicians are corrupt tend to lack important knowledge of politics and public policy. Not knowing the name of the House Majority Whip or the difference between an authorization and an appropriation is understandable, yet there is something wrong about a physician who says they have “given up” on politics, but cannot describe the difference between Medicare and Medicaid or how these programs impact the daily lives of our patients. Physicians lost the privilege of giving up on politics decades ago. Three years from now, the first baby boomers become eligible for Medicare. The Government Accounting Office (GAO) reports that Medicare and Medicaid’s burden on the economy will almost quadruple, from 4.7% to 17.7% of the economy, by the year 2080.11 As budgetary pressures on Medicare and Medicaid increase, physician stress and patient suffering will also increase. We cannot isolate ourselves from the political process at a time when our patients most need us to advocate for comprehensive health care reform. Some scholars suggest that physicians’ political influence has been diluted by the emergence of powerful, competing subspecialties in medicine.12 Others suggest that physician political power has been upset by the “corporate transformation” of medicine where physician control of services is usurped by insurance companies, HMOs, and government regulators.13 Still others feel that physicians are simply outspent and outnumbered by the drug and medical device companies.14 The waning influence of physicians is a complex, multifactorial phenomenon, yet it has less to do with a splintered AMA, or expensive drug company lobbyists, and more to do with physicians’ poor personal commitment to advocacy. As physicians, we must all make a sincere and sustainable individual commitment to lobbying. There are literally hundreds of opportunities to lobby for our patients individually, collectively, locally, federally, and on the state level. Physicians can involve themselves in regulatory processes such as those for OSHA and the FDA. We can also write op-eds for the local newspaper or volunteer for one of the many patient rights groups or state medical society committees. As leaders in our communities, we should meet with our local elected officials and offer assistance to their staff members. We should also make ourselves available to our lobbyists working in Washington, DC, and in state capitals across the nation. There should be teams of volunteer physicians across the nation, representing each Congressional District and ready to travel on a moment’s notice to meet with decision-makers. Second, we must reprioritize our political spending so that lobbying becomes a primary focus. While the details of a comprehensive lobbying strategy are complex (i.e., what issues to lobby, what strategies to employ, and how to incorporate conflicting special interests), our lobbying goal is straightforward. We want our lobbyists to develop day-to-day relationships with decision-makers that rival those relationships cultivated by the drug and medical device industry. Finally, we must accept a less self-centered view of health care reform. While physician reimbursement and malpractice campaigns are important, they are perceived to be selfish in the eyes of many decision-makers.10 We need to choose one or two bills championed by patient rights groups each year and support them with the same fervor and resources we apply to malpractice reform or reimbursement protection. Not only is this the right thing to do, it will enhance our legislative influence and public support. Physicians may be the only stakeholder left in health care who can achieve what the drug companies have done legislatively. If we develop a patient-centered legislative agenda, make personal commitments to engage our political system and divert more of our political resources to lobbying, we may have some success. For our patients, our staffs, and our families, the time for physicians to recapture our political dominance in health care is long overdue.

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