reflection 2 6

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.

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

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

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

Conclusion

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.