Landers SH, Sehgal AR. How Do Physicians Lobby Their Members of Congress?. Arch Intern Med. 2000;160(21):3248-3251. doi:10.1001/archinte.160.21.3248
Copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2000
Physicians are uniquely qualified to educate legislators about health care issues, but little is known about how physicians lobby members of Congress.
From the staff of 84 randomly selected members of Congress (49 senators and 35 representatives), we interviewed the legislative assistants who work on health care legislation and meet with constituents and lobbyists on behalf of their senator or representative. We asked about (1) the frequency of meetings between legislative assistants and physicians, (2) the issues discussed, and (3) the perceived effectiveness of lobbying.
Senate and house legislative assistants met with an average of 10.0 and 4.0 physicians per month, respectively. This suggests that approximately 29,000 such meetings occur annually. The most common issues discussed were Medicare reimbursement (mentioned by 67 [81%] of 83 subjects), managed care reform (62 subjects [75%]), and funding for medical research (21 subjects [25%]). Other issues, such as access to care for the uninsured, tobacco control, abortion rights, and violence prevention, were rarely discussed. Most legislative assistants rated physicians as effective (37 [44%]) or somewhat effective (39 [46%]) as lobbyists. The most common suggestion for improving physician lobbying was to focus less on reimbursement and to address a broader range of health care issues.
Physicians are frequent and effective lobbyists on reimbursement, managed care, and research issues. Policy makers appear receptive to increased physician input on a broader range of health care issues. Including these issues in lobbying efforts has the potential to shape health policy in a way that improves patient care and public health.
HEALTH POLICY decisions affect virtually all aspects of medical practice, including (1) access, quality, and cost of health care; (2) medical education; (3) research priorities; and (4) physician compensation.1- 4 Because of their expertise as caregivers, researchers, and administrators, physicians are uniquely qualified to educate members of Congress and other policy makers about health care issues.5 Professional guidelines for physicians often stress the need to actively participate in the political process as a way to improve the health care system.6,7 However, with the exception of one report8 by a physician who worked in a senator's office, little is known about how physicians interact with legislators. Studying these interactions may help physicians to become more effective lobbyists.
We, therefore, sought to determine the frequency, content, and effectiveness of physician lobbying of members of Congress. Because lobbyists generally meet with legislative assistants rather than directly with members of Congress, we targeted the legislative assistant responsible for health care issues in each congressional office. These legislative assistants work on health care legislation and meet with constituents and lobbyists on behalf of their senator or representative. Legislative assistants were asked to answer our questions based on meetings with physicians from their home state or district rather than with professional lobbyists hired by medical associations. Members of Congress who sit on health-related subcommittees were oversampled because they may be the focus of more physician lobbying efforts.
Individuals targeted for interviews included (1) all 30 legislative assistants working for senators who sit on health-related subcommittees, (2%) all 30 legislative assistants working for representatives who sit on health-related subcommittees, (3) 50 randomly selected legislative assistants working for senators not on health-related subcommittees, and (4) 130 randomly selected legislative assistants working for representatives not on health-related subcommittees. The 2 senate health-related subcommittees are the Appropriations Subcommittee on Labor, Health, Human Services, and Education and the Finance Subcommittee on Health. The 2 house health-related subcommittees are the Appropriations Subcommittee on Labor, Health, Human Services, and Education and the Ways and Means Subcommittee on Health.
One of the investigators (S.H.L.) telephoned targeted congressional offices from June to August 1999, identified the legislative assistant responsible for health care issues, and described the project. He then asked consenting legislative assistants about the following:
How many physicians from their state or district visit their office in a typical month.
What issues the last physician they met with discussed.
To name the 3 most common issues physicians generally discuss.
To rate how much physicians lobby in support of 9 specific issues (listed in Table 1). Subjects answered this question on a 4-point Likert scale ranging from "a lot" to "not at all."
To identify issues on which they would like more input from physicians.
To rate the effectiveness of physicians as lobbyists. Subjects answered using a 4-point Likert scale ranging from "very effective" to "not at all effective."
How physicians could be more effective in communicating with members of Congress.
Specific items for question 4 were selected from (1) health care issues discussed frequently in newspaper and television reports and (2) legislative agendas of several medical professional organizations.9- 13 Copies of the questionnaire are available from the authors.
Descriptive statistics (means and percentages) were used to analyze subject responses. The χ2 test was used to examine party affiliation among subjects compared with Congress as a whole. The Mann-Whitney rank sum test was used to examine the relation between health-related subcommittee membership and number of physician contacts.
Of the 191 targeted legislative assistants, 71 said their office had a policy against participating in surveys. Of the remaining 120, 84 (70%%) completed interviews, while 36 (30%) could not be reached after 5 attempts. Of the 84 participants, 69 completed telephone interviews, while 15 preferred to complete the survey via facsimile or e-mail. Of these 84 legislative assistants, 49 (58%) worked for senators, 35 (42%) worked for representatives, and 28 (33%) worked for members of health subcommittees. Also, 48 (57%) of the participants worked for Republicans and 35 (42%) worked for Democrats. This is not significantly different from the party affiliation of all 535 members of Congress (51% Republican and 49% Democrat; P = .33).
Senate legislative assistants reported an average of 10.0 meetings per month with physicians from their state, while house legislative assistants reported an average of 4.0 meetings per month with physicians from their district. House legislative assistants who worked for members of health-related subcommittees reported more meetings than those not involved in such subcommittees (7.0 vs 2.9; P = .01). There was no relation between health subcommittee membership and senate legislative assistant reports of physician meetings. Since there are 100 total senators, 30 representatives on health subcommittees, and 405 representatives not on health subcommittees, we estimate that approximately 29,000 meetings occur annually between physicians and health legislative assistants.
In response to 3 separate questions, legislative assistants described the content of their discussions with physicians. First, when asked about their most recent meeting with a physician, legislative assistants said the most common issues discussed were increasing or maintaining Medicare reimbursement (25 [30%]) and managed care reform (25 [30%]). Other less commonly discussed issues included increased funding for medical research (7 [8%]), helping physicians unionize (7 [8%]), funding graduate medical education (5 [6%]), access to health insurance (4 [5%]), and limiting the role of nurse anesthetists (2 [2%]).
Second, when asked to describe the 3 most common issues physicians generally discuss, legislative assistants mentioned increasing or maintaining Medicare reimbursement (67 [81%]), managed care reform (62 [75%]), and increased funding of medical education (21 [25%]). Other less commonly discussed issues are as follows: limiting Medicare fraud and abuse enforcement (7 [8%]), helping physicians form unions (5 [6%]), complaints about the burden of paperwork (4 [5%]), limiting the role of nonphysicians (4 [5%]), and helping the uninsured gain access to health care (4 [5%]).
Third, when asked about a list of specific issues, legislative assistants reported that physicians lobby a lot for increasing or maintaining physician compensation, increased funding for medical research, improving the future viability of Medicare, giving patients the right to sue their health maintenance organization, and increased funding of medical education. By contrast, malpractice tort reform, better access to care for the uninsured, tobacco control legislation, and abortion rights received little or no attention (Table 1).
Fifty-three legislative assistants mentioned issues on which they would like more input from physicians. These included access to care for underserved populations (10 [19%]), specific experiences with managed care (8 [15%]), medical research priorities (8 [15%]), endorsing a version of the Patient's Bill of Rights (5 [9%]), ideas for improving health outcomes (4 [8%]), and tobacco control legislation (3 [6%]).
Most of the legislative assistants said that physicians were either very effective (37 [44%]) or "somewhat effective" (39 [46%]) at communicating their message. The legislative assistants were asked to give suggestions that would make physicians more effective lobbyists. The most common suggestions were to talk less about reimbursement and self-interest and more about a broader range of health care issues (15 [18%]), to know more about the legislative process and the background of specific issues (8 [10%]), and to use real-life examples of how health policy decisions affect their patients (8 [10%]). Other suggestions included the following: to lobby less frequently through national professional associations (7 [8%]), to demonstrate how specific issues affect their state or district (7 [8%]), and to contact Congress on a consistent basis (6 [7%]).
Two quotes illustrate these results. One legislative assistant said, "physicians should beware of the impression that their main concern is reimbursement rates." Another commented that physicians should "convey passion . . . and recognize the power they have to influence Congress."
We found that physicians frequently lobby members of Congress and estimate that 29,000 meetings occur annually between physicians and health legislative assistants. The most common issues physicians discuss relate to reimbursement, managed care reform, and medical research funding. By contrast, other issues such as access to care for uninsured citizens, tobacco control, abortion rights, and gun violence are rarely brought up by physician lobbyists. Most health legislative assistants rate physicians as effective lobbyists. However, many legislative assistants expressed an interest in having physicians include a broader range of health care issues in their lobbying efforts.
With the exception of managed care reform, the issues physicians lobby about are different from the health care issues voters want Congress to address. A recent survey14 found that the 4 issues of most interest to voters were making Medicare financially sound, helping the uninsured get health insurance, managed care reform, and tougher gun control laws.
Several features of this study make our finding especially noteworthy. This is, to our knowledge, the first study to systematically describe physician lobbying of Congress. In addition, the results come directly from the individuals who meet with physician lobbyists on a regular basis. We were able to interview a large, representative sample of health legislative assistants, including many who work on health-related subcommittees. Finally, legislative assistants were asked about the content of physician lobbying in multiple ways and provided similar answers regardless of the format of the questions.
We recommend that physicians include a broad range of health care issues in their lobbying efforts. Our findings suggest that such efforts would be welcomed by legislators and effective in positively influencing health policy decisions. This does not mean physicians need to abandon lobbying about financial issues. Like any other group, physicians have a right to inform policy makers about issues that affect their livelihood and working conditions. Other recommendations for improving physician lobbying include learning more about the legislative process, using real-life examples of how policy is affecting their patients, and contacting Congress on a consistent basis. The suggestion to be better informed about the legislative process is consistent with previous work15 showing that physicians are poorly informed about medical socioeconomics and politics.
While our study was not designed to determine the role of medical associations, it is likely that some physician lobbying is organized or facilitated by medical associations.16,17 Such professional associations may consider including a broad range of issues in their lobbying efforts. In addition, teaching medical students about health policy may stimulate them to interact with policy makers in the future.18 Legislators should also actively seek input from physicians in their state or district about health policy issues.5
Several limitations must be considered in interpreting our findings. First, it is possible that legislative assistants who meet frequently with physicians were more likely to agree to participate in our study. Thus, our findings may overestimate the frequency of physician lobbying. Second, this study was not designed to determine the impact of physician lobbying on the attitudes of the representatives and senators who ultimately cast votes on health care legislation. Third, the specific health care legislation being discussed in Congress at the time of our interviews may have influenced physician lobbying efforts. For example, during the summer of 1999, managed care reform legislation was being considered by Congress.19 By contrast, no major tobacco control legislation was being considered at that time. However, several legislative assistants specifically expressed disappointment at the lack of physician input the last time Congress did consider tobacco control legislation. Fourth, physicians can influence health policy decisions in other ways, such as holding elected office, writing letters, doing policy-relevant research, and making campaign contributions.20,21 Additional studies are necessary to fully characterize the role physicians play in shaping health policy.
In conclusion, physicians are frequent and effective lobbyists on reimbursement, managed care, and research issues. Policy makers appear receptive to increased physician input on broader health care issues. Including these issues in physician lobbying efforts has the potential to shape health policy in a way that improves patient care and public health.
Accepted for publication June 30, 2000.
We thank the participating legislative assistants. Without their help and encouragement, this project would not have been possible. We also appreciate the input of students and lecturers in the course "Activism and Medicine" at Case Western Reserve University, Cleveland, Ohio.
Reprints: Ashwini R. Sehgal, MD, Division of Nephrology, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109-1998 (e-mail: firstname.lastname@example.org).