reflection 2 5

Reflection #2

Complete this week’s assigned readings, chapter 72 After completing the readings, post a short reflection, approximately 1 paragraph in length, discussing your thoughts and opinions about one or several of the specific topics covered in the textbook readings pertaining to health policy and politics. Identify which one MSN Essential most relates to your selected topic in your discussion.

See bellow for chapter 72 and see attached for MSN Essentials

Chapter 72 Interest Groups in Health Care Policy and Politics

Joanne R. Warner

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

Paul Wellstone

The ink from President Obama’s pen was hardly dry as he signed the Patient Protection and Affordable Care Act (ACA) into law before interest groups were considering how to stall or prevent its implementation. In fact on that very day, March 23, 2010, a suit was filed declaring the law unconstitutional. Included in the suit’s supporters were private interest groups such as Citizens United who objected to the law’s mandate to buy insurance or pay a penalty. A legal conclusion to their questions came in a June 2012 Supreme Court ruling upholding the individual mandate, but striking down the requirement for states to expand Medicaid (Clemmitt, 2012). The legislative journey for the ACA presents many examples of interest group influence, including the citizen activists’ organization Americans for Prosperity, who continue to cast doubts on the ACA’s merits, warning that the implementation is “chaotic and frustrating” (Peters, 2013, paragraph 4). What promises to unfold for the ACA is the robust involvement of interest groups vociferously defending their preferences in the structure and financing of America’s health care system.

Interest groups play a significant role in health care reform. However, they are a paradox within our governing system. We need and value them but at the same time they annoy and distract us. We embrace them as empowered citizen involvement, and we resent the perception of buying elections and votes. The love-hate ambivalence is born, in part, from the way a 1787 notion has translated into today’s Washington-centric political era. Democracy within our individualistic 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, federal, state, and local political arenas 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 of interest groups, describes their functions and methods, and concludes that they embody the good, the bad, and the ugly of governance. 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) forms 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. Later, the French philosopher Alexis de Tocqueville observed the country from an outsider’s view. 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, 1835/2010).

The impetus to organize exists not only within the American people but also within the political structure. Groups can influence policy through elections, lobbying the legislature, and pressuring the executive branch of any level of government.This diffusion of power presents many opportunities for persuasion. It also allows interest groups to shop for a different level of government if they are unhappy with policy; for example, federal versus state government (Anderson, 2011).

Historically, groups formed around interests such as slavery and alcohol prohibition. At the turn of the twentieth century, interest groups based in Washington blossomed. The social activism of the 1960s generated more groups focused on civil rights, the environment, and specific economic and humanitarian causes (Nownes, 2013). As the power and money of interest groups grew, Congress acted to restrict their influence and limit direct contributions to candidates. However, the reforms that grew from the Watergate scandal of the 1970s inadvertently enhanced their power by promoting the formation of political action committees (PACs). The Bipartisan Campaign Reform Act of 2002 (the McCain-Feingold Act) revised the Federal Election Campaign Act of 1971 to control soft money contributions, that is, funds funneled through political parties to candidates, and the funding of issues ads (Federal Election Commission, 2013a). For good or ill, special interest money continues to grease electoral and political wheels.

From this historical perspective, several kinds of groups are in existence today: the trade unions and business associations that advance their economic interests, and the groups representing newer social movements (Fiorina et al., 2009). Within the latter group, there are interest groups that provide information and are active in the current health care reform debate. Examples include the U.S. Public Interest Research Groups (USPIRG), who “stands up to powerful interest when they threaten our health and safety” or when big money dominates the dialogue (U.S. Public Interest Research Groups, 2013); Essential Action, which wages campaigns on topics not visible in the mass media or on political agendas including access to medicines and the global effort to reduce tobacco use (Essential Information, 2013); and the Center for Science in the Public Interest (CSPI), whose consumer advocacy in health and nutrition involves novel research, providing information, and ensuring that science and technology serve the public good (Center for Science in the Public Interest [CSPI], 2012). These examples demonstrate the enduring nature of interest groups juxtaposed as an evolving list of groups and issues.

When is an 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 group but whose funds and agendas are from an industry or political party. For example, the Center for Consumer Freedom, which has a mess­age of individual choice but is a front group for the restaurant, alcohol, and tobacco industries. This group opposes public health messages of science, health, 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). 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 the source of a group’s funding can limit harmful misrepresentation and highlight how ideological arguments can diminish the power of solid science and research in policymaking (Apolionio & Bero, 2007). The presence of front groups calls each consumer to vigilance about the bias and intention of groups who advocate and provide information.

Functions and Methods of Influence

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


Lobbying involves the direct influence of public officials and their decisions. Wolpe (1990) presented a concise description of lobbying as “the political management of information” (p. 9) because it involves educating, shaping opinions, and offering 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; this also allows for ongoing relationships between staff, officials, and lobbyists to be the foundation of influence. Lobbyists become adept at the nuances of the legislative process and can provide nimble responses.

The largest number of registered federal lobbyists recorded to date is 14,842 in 2007 and the largest total lobbying expenditure was recorded at $3.55 billion in 2010. In 2012, 12,407 federal lobbyists were a part of $3.31 billion lobbying spending (Center for Responsive Politics, 2013a). Of the top 8 lobbying industries in 2013, four are related to health: insurance, hospitals, pharmaceuticals, and physicians, in order of size (Center for Responsive Politics, 2013b). Lobbying is thus a substantial business.

Grassroots Mobilization

Grassroots mobilization involves indirectly influencing officials through constituency contact. More decentralized politics and expanded communication options make grassroots involvement effective. Pseudo-grassroots efforts that mobilize technology more than citizens are mockingly called AstroTurf lobbying; another version is grass-tops lobbying, when a prominent personality champions an issue. Most interest groups employ some version of grassroots mobilization (Bergan, 2009).

Electoral Influence

Electoral influence can be considered the primary prevention of policymaking because it is an important activity that precedes policy work. It determines who is elected to shape future policies (Warner, 2002). Successful electoral campaigns need three resources: time, money, and people. Interest groups can provide the last two. 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 federal candidates who are aligned with the ANA agenda and values, with the ultimate intent of improving the health care system (ANA, 2013). As a result of campaign reform efforts in 2002 the influence of PACs has been contained. During 2013 to 2014 PACs can only donate $5000 per election (primary, general, or special) and $15,000 annually to a national party, although individuals can give up to $2600 per year to each candidate (Federal Election Commission, 2013b).

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. It is similar to an infomer­cial that sells an issue or to direct mail blanketing an area with information promoting a particular perspective. The impression of societal consensus could, in turn, persuade policymakers as they create policy. These initiatives either cost money or are free media in the form of news coverage.


Lastly, litigation can 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 that organized 200 plaintiffs in five states to bring cases of racial segregation and discrimination in schools to the Supreme Court. This ruling affected racial discrimination throughout society and inspired interest groups to pursue their proposed change through the court system (Brown Foundation for Educational Equity, Excellence and Research, 2012).

To create their action plans, each interest group develops a distinct identity that originates in its methods, 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 is the question of effectiveness. The critique ranges from the good to the bad and the ugly. Many maintain that they successfully enhance our democratic processes and actualize our early vision of democracy, as argued by James Madison. In doing so, they prevent violence and tyranny by engaging citizens in social change through other means. In theory, groups represent our pluralistic and transparent government. In practice, scholars believe that opposing groups’ lobbying, media, or actions often cancel out their cumulative influence (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 country’s well-being cannot be achieved through the collective concerns of special interests and that the policy process grinds into inaction with too many special groups vying for their own advantage (Rauch, 1994). Quadagno (2005) presents a bold example of demosclerosis by concluding that health care reform has been thwarted over the years by special interests and that these groups are the “primary impediment to national health insurance” (p. 207). Even as the antireform coalition has changed over the years from primarily physicians to insurers, its goal of inertia and status quo has prevailed over the reformers’ efforts. The chronicle of the ACA provides contemporary examples.

Landscape of Contemporary Health Care Interest Groups

A Pittsburgh Post-Gazette editorial warned then 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 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?

Funds from interest groups are predominantly spent on lobbying and on campaign contributions, and the health industry is heavily involved in both. The Center for Responsive Politics (a nonpartisan research group that tracks money in politics) ranked the health sector as the sixth largest interest group contributor. During the 2012 election cycle, health professionals contributed a record $260.4 million to federal candidates; although Republicans received a larger proportion of those funds, nurses traditionally favor Democrats. Lobbying expenditures from the health care sector peaked in 2009 at $552 million as the ACA was being created. The pharmaceutical industry dominated the 2012 spending by contributing $235 million of the total $487 million of health spending (Center for Responsive Politics, 2013c). Stakeholders concerned with health care reform also include those outside the health industry (e.g., insurance corporations, labor unions, and myriad business and consumer groups). In fact, from an ecological perspective, most topics eventually trace back to health and the human potential it impacts.

Table 72-1 presents campaign contributions made by health professionals from 1996 to 2012, including both health professional PACs and individual contributions. It demonstrates dramatic increases in contributions and variation in the partisan allocations, usually related to whatever party is in power. Clearly, health professionals are engaged in electoral politics.

TABLE 72-1

Health Professionals’ PAC and Individual Contributions to Campaigns

Election Cycle Total Contributions % to Democrats % to Republicans
2012 $152,275,788 43 57
2010 $77,614,465 48 52
2008 $101,791.889 53 47
2006 $56,758.918 38 62
2004 $75,280,121 37 63
2002 $42,738,790 38 62
2000 $48,042,286 42 58
1998 $31,587,151 41 59
1996 $37,811,666 36 64

Nursing has experience and success with collective involvement in campaigns. The American Nurses Association (ANA) has provided a collective voice and presence in Washington from 1974 to the present. Their goal is the “improvement of the health care system in the United States” by contributing to candidates who support the ANA policy agendas (American Nurses Association [ANA], 2013a, p. 1). Decisions to endorse candidates are made by the Board of Trustees. It is important to realize that endorsement decisions are based on agreement with ANA’s policy stands and not on the candidate’s party. In the 2012 cycle, 82% of their $542,500 contributions went to Democrats and 16% to Republicans (Center for Responsive Politics, 2013d). Table 72-2 lists contributions of nursing PAC contributions to federal candidates in 2012.

TABLE 72-2

Nursing PAC Contributions to Federal Candidates

Nursing Political Action Committee Amount Contributed
American Association of Nurse Anesthetists $683,800
American Nurses Association $542,500
American College of Nurse Midwives $70,500
American Academy of Nurse Practitioners $63,050
American College of Nurse Practitioners $26,500

Trended data provide interesting information about the choices that nurses make for their collective electoral influence. The ANA PAC raised and spent over $1 million in one election cycle (1994) but has not reached that amount since. Contrast this to trended data about the American Association of Nurse Anesthetists whose PAC has exceeded $1 million in every election cycle since 2000, with a record high of $1.6 million in 2008 (Center for Responsive Politics, 2013d, 2013e). A simplistic assumption is that nurses donate closer to their specialty, yet the fuller explanation is likely more complex and not yet explained.

When the campaign dust settles and policy-making continues, lobbyists base their advocacy on the values and positions of the group. The ANA, for example, has a long history of supporting universal access to quality health care and advocating for a system that serves the interests of both patients and nurses (ANA, 2013b). The key elements of the 2008 Health System Reform Agenda continue to be relevant standards and values that infuse into ongoing reform efforts: access, quality, cost, and workforce. The ACA addresses most of these elements except health care as a human right for all and public funding through Medicaid expansion (ANA, 2010).

The landscape for health care reform therefore is populated with many interest groups, some in the health industry and many with vested interests in the cost and structure of the reform efforts. Significant money goes into elections and lobbying and nursing is involved in both. Although it may not be ranked as one of the most powerful groups, its political currency is trust, integrity, and a reputation for championing quality care for all within an equitable and accessible system.

Assessing Value and Considering Involvement

Most choices involve a “what’s-in-it-for-me?” appraisal. In addition to that discernment, the robust ambivalence surrounding interest groups heightens the need for evaluation criteria. How can nurses and other health care providers assess the qualities of an interest group? Where should they allocate their finite resources of time, energy, money, and reputation?

Table 72-3 portrays queries that provide a framework for discernment to assess an interest group and determine the extent of involvement. The framework also provides language and justification for decisions. This approach matches the spirit, though not the rigor, of the scientific evidence-based nature of the health care profession. The nine queries are not listed by priority, as the weight of their importance will differ according to the individual. Nurses can engage in the discernment and defend their involvement in terms of the nine guiding principles, which may prove more thoughtful than replicating the behaviors of our parents or simply following the crowd.

TABLE 72-3

Framework for Assessing Interest Groups

Factor Questions to Assess the Factor in an Interest Group
Efficiency What portion of the group’s budget supports advocacy, education, or the social interest represented, compared with the portion that supports the group’s infrastructure, overhead, or administration?
Effectiveness What is the track record of accomplishments related to education, awareness, legislation, or cultural change? What outcomes can be credited to the group, either individually or in coalition?
Values Do the values of the group align with your personal, political, and professional values? Do your beliefs match the values that inspire the group’s work? Does this work stir some passion in you?
Tactics Do you support the methods used by the group? Do the tactics match your preferred approach to social change, including options such as violence, protesting, nonviolent resistance, media campaigns, or organized action?
Visibility and responsiveness Does the group have the level of public visibility that you prefer? Do they employ the level of outreach to their members that you prefer? Do they communicate clearly and consistently with the constituency?
Social norms Does the group match your local culture and the social norms of the people with whom you associate? Would your involvement in this group change the way people perceive you personally or professionally? Does that perception matter to you?
Perception What is your perception of the leaders and key stakeholders of the interest group? Does that perception matter to you?
Costs What would involvement require of you? Are there dues or voluntary financial commitments? Can you contribute the amount of time required? Will they ask to use your name, title, or reputation, and will any unintended implications involve professional cost? Does your employer prohibit or discourage involvement with this group?
Benefits What’s in it for you? Will you obtain any profit, professional advantage, or membership benefits? Do you value the social benefit of association? Are you willing to be involved for altruistic intentions? Are you willing to be involved if the benefits go to others, for example, an underrepresented population, the environment, or a cause beyond your immediate life?


In a democracy, interest groups are integral to the governing process. They are sanctioned by our Constitution and valued as a vehicle for citizen participation, but are also despised as an underhanded wielding of influence through money. Despite societal ambivalence, they are likely here to stay. Perhaps the best approach is to cleverly frame them. As Republican strategist Mary Matalin whimsically noted, “They’re stake-holders when they’re with you, and they’re interest groups when they’re against you” (Espo, 2009, paragraph 8). Or perhaps the best advice is to intentionally discern our own involvement, know the rules of the game, and use interest group power to further the causes we treasure.

Discussion Questions

1. In what ways is, or is not, the nursing pro­fession a special interest group in American democracy?

2. What strategies would enhance the effective influence of nurses as a collective special interest group in policy advocacy and electoral politics?

3. What role does the nonpartisan stance of nursing PACs play in the broad engagement of nurses in electoral politics and policy advocacy?


American Nurses Association [ANA]. ANA policy & provisions of health reform law. [Retrieved from]

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