Influential Players: How Six Big Stakeholders Shaped Health Care

The biggest players in the health care reform debate often blur together into a swirl of acronyms and policy jargon. But they’re also key to understanding how health care reform has been shaped, and how it’s come as far as it has.

At this point in the health care debate, pro-reform groups have spent more money on health care ads than have well-heeled health care opponents. That’s a testament to just how important the issue is to the liberal base, but it’s also the precise effect President Obama was seeking when he partnered with the health care industry’s most powerful stakeholders.

What sets the following six players apart is how they’ve defied the usual expectations and taken positions that don’t easily fit into the usual left vs. right or corporate vs. consumer paradigm.America’s Health Insurance Plans

AHIP, better known to most as the health insurance lobby, probably had more to do with the failure of President Clinton’s health care reform effort than did any other industry association. Relative to that turbulent era, this year, the organization has been fairly quiet, but it’s also become the redheaded stepchild of the stakeholder associations. Its goal has been fairly simple: support strong mandates, weak regulations, and demonize public competition–and if that doesn’t succeed, to tank the project. For months, AHIP played this game masterfully–nominally supporting reform, declining to run Harry & Louise-type ads that proved so effective in the early ’90s, while also enlisting citizens to “raise concerns” at health care protests, and wage war against the public option. That slippery strategy worked pretty well until last month, when the group commissioned a deceitful study to scare voters into believing that health care reform would break their banks. Since then, AHIP has jumped ship, but possibly too late, and certainly after great harm was done to the insurance industry’s already sullied reputation.


The most insider-y of the insiders. The Pharmaceutical Research and Manufacturers of America is perhaps the best moneyed, and therefore most influential industry group to count itself on the side of reform. That’s probably why the White House and Senate Finance Committee Chairman Max Baucus handed PhRMA the sweetest deal of any of the industry stakeholders. Drug manufacturers agreed, by accepting a handful of regulatory changes, to provide $80 billion over 10 years to help cover the cost of reform legislation. In return, a coup: the administration vowed not to overturn their hard-won victories, such as a ban on drug re-importation and a promise from the government not to bargain down the price of prescription drugs. This deal was threatened when it was made public earlier this year by PhRMA-chief Billy Tauzin, but has thusfar survived the Senate’s grueling legislative process. One potential problem: The House was not a party to the deal, does not approve of it, and its legislation does not enshrine it. That could lead to a situation in which Obama has to choose between either alienating his liberal base or alienating a powerful political money-giver. That’s a dilemma worth keeping an eye on.


The elderly are skeptical of reform. The Republicans caught on to that early, and that’s why the summer was sopped with spurious warnings about death panels and cuts to Medicare. They elderly also vote. And without the early and continued support of their main lobby, the reform effort might have been toppled long ago. The administration will likely return to Medicare when it turns its attention to pressing fiscal challenges, and there the AARP will likely play a greater role. In this effort, though, they secured the closing of the “donut hole”–the Medicare prescription drug coverage gap–and gave their blessing the government to rein in Medicare Advantage overpayments, and other Medicare reforms. They endorsed the House health care bill last week.

The American Hospital Association

The AHA has been a big, but quiet player in the reform fight. They agreed to a $155 billion in payment cuts over 10 years to help cover the cost of the overhaul. In return, they expect a new treatment landscape–electronic records, reduced bureaucracy, no more (or many fewer) uninsured patients, without taking a significant hit profit-wise. That’s why they were concerned about (though not adamantly opposed to) a public option, which was originally conceived as a major insurer that paid Medicare rates to health care providers. As it turns out, the public options being considered by both the House and Senate are much more modest creatures, unlikely to cause hospitals to revolt.

The American Medical Association

The AMA is not Washington’s most influential lobby. But doctors are a fairly beloved, and conservative constituency, and if they’d raised hell about reform–if they, and not Republicans, had been the ones warning patients about government bureaucrats coming between them and their doctors–Democrats would have had a difficult time calming voter fears. Basically, doctors don’t want pay cuts, and would like to deal with less bureaucracy. They tepidly opposed a public option, and were disappointed when Republicans and some Democrats killed a bill that would have reformed Medicare’s physician payment formula. But in the end they got most of what they wanted, and endorsed the House’s health care bill last week.

Health Care for America Now

There are more pro-reform groups working to pass a bill–unions and consumer groups and health care issue organizations and so on–than a single journalist could possibly describe. Some have played the inside game (the Service Employees International Union), others have been less beholden to the White House’s line (AFL-CIO) but dozens of them, from across the spectrum, aligned under HCAN’s wide umbrella. HCAN has spent millions of dollars on a campaign for a comprehensive health care bill. To the extent that liberals and reformers have a single basic understanding of what constitutes a public option, it’s because HCAN defined it and helped organize around it. HCAN’s efforts haven’t been as punchy as some of the more liberal groups would have liked, or as passive as the Obama administration might have preferred. But the group has the ear of the White House and key players in Congress, and has used that access at times to great effect.