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Editorial |
1 From the Mallinckrodt Institute of Radiology, 510 S Kingshighway Blvd, St Louis, MO 63110 (J.J.B.); and the Barnes-Jewish Hospital, St Louis, Mo (R.G.E.). Received February 24, 1999; revision requested April 23; revision received June 16; accepted August 9. Address reprint requests to J.J.B. (e-mail: brownj@mir.wustl.edu).
Index terms: Editorials • Radiology and radiologists • Radiology and radiologists, socioeconomic issues
The idea of political advocacy is unfamiliar to many radiologists. The demands of day-to-day radiologic practice make political activism a challenge. Understanding the role of lobbying should help radiologists to make an informed decision with regard to their own level of political involvement.
The purpose of this article is to describe interest group lobbying and its role in the American legislative process. A basic overview of interest group lobbying is presented and is followed by brief descriptions of two existing radiology advocacy groups.
Lobbying and Interest Groups
Lobbying is an attempt by an individual or an organization to influence public policy decisions. If successful, it can result in favorable legislation that benefits the lobbyist and the group he or she represents. Lobbying is tightly woven into the American political fabric and plays a role in nearly every major governmental decision (1, p 13). Most bills passed by the U.S. Congress are described in the media as a victory or a defeat for at least one lobbying group.
Although lobbying serves important purposes, it has a mixed (mostly bad) reputation. To many people, the word "lobby" itself implies shady dealings or influence peddling. Lobbying is usually performed on the behalf of organizations such as professional associations, business groups, labor unions, public interest groups, and a large variety of other voluntary organizations and societies.
For the most part, these groups are not viewed negatively in and of themselves. The majority of Americans (57% in a recent poll) belong to at least one voluntary association or interest group (2).
However, when these organizations engage in lobbying, they are typically referred to as "special interest groups," "special interests," "vested interests," and "pressure groups," all of which are terms with negative connotations. In the ensuing discussion, we will rely mainly on the term "interest group," since this seems to be the most neutral phrase.
An interest group is defined broadly as a collection of individuals who share some common characteristic or interest. Interest groups have the potential to become active in the political process, with the goal of influencing some of the decisions made by the government.
There are several reasons for the generally negative public view of lobbying and interest groups. It is natural for people to resent lobbying activities that oppose their positions or beliefs. On the other hand, few people complain about lobbying performed on behalf of causes that they support.
A more valid concern is that some interest groups lobby so effectively that their influence on the legislative process exceeds that of the majority of the population, who may oppose their views. This often relates to the intensity of feeling within an interest group, which has been identified as one of the most important factors in lobbying effectiveness (3, pp 13 and 14).
Congress responds to groups that care deeply about issues. An interest group that is passionate about a particular cause can wield greater political influence than a much larger group of people whose feelings are in opposition but not as deeply held. This may help to explain the success of some groups that represent minority viewpoints.
Public resentment of lobbying also stems from the perception that the legislative process is controlled by a small group of business leaders or wealthy elites, a notion that strikes at the heart of American democratic ideals.
As a result of these concerns, there has been a long-standing movement in the United States to regulate and reform lobbying activities. Recent lobby reform laws have been aimed at restricting gifts and honoraria to lawmakers, at expanding lobbyists' reporting requirements, and at increasing the required level of financial disclosure for public officials.
Campaign finance and, in particular, softmoney contributions are ongoing topics of intense debate. Although the lobby reform movement will continue, it is unlikely that the efforts of interest groups to influence policy making will abate in the foreseeable future. The First Amendment to the U.S. Constitution guarantees the right to freedom of speech and the right "to petition the Government for redress of grievances." Our system of government and the current laws that regulate access to policymakers encourage interest groups to form and to press their demands on elected representatives (3, p 162).
Most interest groups recognize lobbying as an essential activity. Lobbyists can offer a service to policymakers by providing information about issues and constituents' views. Democracy demands that elected officials who face reelection pursue sufficient numbers of votes to win. The rational politician will construct a policy platform with the voters' preferences in mind. Although politicians have several avenues by which they can learn their constituents' views, which include direct communication with individual voters and public opinion polls, lobbying is the most common means by which citizens communicate their preferences to legislators.
Lobbyists also serve an educational role. The myriad issues facing members of Congress are too varied and complex for the individual members to have expert knowledge of each one. Lobbyists provide government officials with a broad range of data, from technical information and statistics to political ideology and opinions. Many lobbyists are experts in the area of legislation that is being considered and can help guide lawmakers' decisions in crafting policies.
On the whole, lobbyists provide the majority of the data used by congressional committees in planning and drafting legislation (4). Lobbyists also serve a liaison function by delivering information about the groups they represent to legislators and by reporting back to their organizations about happenings in Congress, in the White House, and in the regulatory agencies.
Effectiveness
The most effective interest groups have a core ideology that is well known and is universally accepted by its members. The intensity of devotion to this ideology usually correlates with lobbying effectiveness. Small groups that are fighting against great odds or battling for survival tend to be the most intense.
It is more difficult for large interest groups to generate the same level of intensity, but they have other advantages. The American Association of Retired Persons (AARP) is the largest interest group in America, with more than 35 million members (1, p 29). Representing such a large percentage of the electorate gives the AARP tremendous political clout. The AARP is able to recruit and keep new members through the use of selective incentives such as senior discounts for restaurants and airfare.
Forging a strong consensus within an interest group greatly improves its effectiveness. Large organizations are often handicapped by divergent viewpoints among their members. This is one reason the American Medical Association has at times received low marks for lobbying effectiveness despite its size and internal resources (5). High-quality leadership can help to marshal an organization's internal resources for effective lobbying. Old-fashioned virtues such as honesty and hard work also increase a lobbyist's effectiveness.
Direct Lobbying
Lobbying activities can be categorized into two major strategies. Direct lobbying is defined as direct communication with policymakers or their staff, while indirect lobbying involves primarily communication with individuals outside the policy-making community (3, p 35). On the national level, direct lobbying takes place in Washington, DC, while indirect lobbying appeals to the lawmakers' constituents in their home districts.
In direct lobbying, an interest group's information, opinions, or policy preferences are communicated directly to policy decision makers by a representative of the group (ie, a lobbyist). The policymakers targeted by lobbyists are primarily in Congress, in the executive branch of government, or in the regulatory agencies. The ideal lobbyist should be thoroughly familiar with the issues important to the group he or she represents and should be knowledgeable in the legislative and political processes, in the legal nuances pertaining to the group's issues, and in public relations (1, p 79).
Lobbying has become a full-time profession. The old image of the lobbyist wining and dining politicians is less prevalent today than in the past at both the state level and in Washington. Instead of socializing, today's lobbyists spend more time providing policymakers with demographic information and technical data (6). Well-established lobbyists often are able to secure appointments on federal commissions, panels, boards, councils, and advisory committees (1, p 116).
Many lobbyists today are lawyers, former politicians, or bureaucrats (1, pp 92–96). Lobbyists can be selected from the interest group's membership or hired from outside the group. An in-house lobbyist usually has a deeper understanding of the organization's membership and important issues and is more likely to feel a personal commitment to the issues than a lobbyist from an outside firm. Nevertheless, an increasing number of interest groups have hired law firms to represent their interests to policymakers.
Professional lobbyists or lobbying firms offer services such as legal advice, coalition building, public relations, media strategies, advertising, direct mail, economic consulting, political consulting, fund-raising, polling, and event planning. Direct lobbying requires personal access and contact with policymakers. For the lobbyist, this is best obtained by developing a personal relationship with important legislators. The most effective way to communicate with legislators is through face-to-face meetings. However, if a key policymaker is unavailable, it is often helpful to contact staff members such as legal counsels, clerks, and administrative assistants (1, p 111).
Direct lobbying involves contact with both the legislative and executive branches of government. The president actively participates in the legislative process, both as an initiator of policy proposals and as a lobbyist for or against legislation brought before Congress. The chief executive also engages in indirect lobbying by going to the public to try to convince them of the wisdom of his or her proposals.
The independent regulatory agencies, such as the U.S. Food and Drug Administration, have a substantial influence on government policy and are frequent targets of lobbyists. They have the legislative authority to issue rules that govern their assigned industry groups that are in "the public interest, convenient and necessary" (7). They also work closely with the congressional committees that deal with legislation pertinent to their corporate clientele (1, p 259). Interest groups lobby regulatory agencies through direct contact and by supplying them with information used to help prepare recommendations to Congress.
Although designed to safeguard consumer interests and to regulate private industry, regulatory agencies have a tendency to promote the interests of the industry they are assigned to regulate. The cozy relationship between interest groups, regulatory agencies, and congressional committees or subcommittees has been termed the "iron triangle" (1, p 263). The term refers to the perception that when all three members of the iron triangle share influence, information, and favors, they can pursue favorable policies in a manner almost impervious to outside pressures.
Interest groups are far more effective at preventing unwanted legislation than they are at getting favorable new policies passed. There are ample opportunities to ambush a piece of legislation as it makes its way through the legislative maze. Successful lobbying may result in the passage or defeat of a specific bill, but more often it is determined by the insertion of a paragraph or even of a single sentence into a bill or committee report (1, p 108).
Political action committees (PACs) have emerged as the dominant tool used by interest groups to influence election campaigns. The explosive growth of PACs has been fueled in part by changes in federal campaign finance laws. Political reforms in the 1970s, such as the 1974 Campaign Finance Law, were designed to limit the influence of interest groups in the electoral process; however, in fact these laws have boosted the growth of PACs (1, p 197).
There has been a 500% increase in PAC contributions to political campaigns since 1977 (1, p 201). PAC contributions at the state level have also increased, although many states place limits on the amount of money that can be contributed. Interest groups contribute to PACs mainly to secure access to state and federal policymakers. Some observers argue that PAC campaign contributions are the modern equivalent of a political bribe.
However, research into the effect of PAC contributions on congressional voting patterns has produced mixed results. Some study findings suggest a link between PAC contributions and subsequent votes on public policy, while others show no influence on legislative behavior (8–11).
PAC opponents have argued that PACS do not adequately represent the full range of interests in American society, while proponents defend PAC contributions as being a form of political free speech protected under the First Amendment. Although periodic PAC reforms are introduced in Congress, it seems clear that for the foreseeable future, PACs will continue to play an important role in transferring funds from interest groups to state and national politicians.
Indirect Lobbying
Indirect lobbying, also referred to as grassroots lobbying or outside lobbying, involves mobilization of individuals outside the policy-making community to contact legislators and policymakers (3, p 4). Indirect lobbying tactics include (a) letter writing campaigns to members of Congress (and sending telegrams, faxes, or e-mail); (b) advertising policy positions through the media; (c) writing editorials in local newspapers; (d) fund-raising through direct mail; (e) publicizing candidates' voting records; (f) holding public meetings; and (g) sponsoring boycotts, protests, or public demonstrations (3, p 35).
Indirect lobbying is now used by most interest groups to supplement their direct lobbying activities (1, p 168). The goal is to generate political influence in the home districts of members of Congress by educating the public and by mobilizing interest group members to contact legislators to let them know their preferences. Elected officials are likely to be more receptive to the wishes of their home district constituency than to direct appeals in Washington from national organizations.
The increased role of state government in crafting legislation has boosted the importance of lobbying on state and local levels. Interest groups aim to protect their political agendas in the state legislatures as well as in Congress.
The most common indirect lobbying tactic is the letter-writing campaign (1, p 168). According to Thomas Raisback, the former Republican representative from Illinois, "The most effective lobby campaigns involve the local constituency. . . . If you get a letter from a constituent, you pay attention. . . . He is somebody who votes for or against you" (12). More than 70% of the members of Congress who were surveyed in a Gallup poll rated personal letters from constituents as having a "great deal of influence" on their legislative decisions (3, p 74).
On the other hand, mass mailings have probably reduced the effectiveness of letter-writing campaigns. Each member of Congress receives an average of 400 letters and postcards per day. Most of them are read only by legislative assistants.
To maximize the effect of a letter-writing campaign, the letters should focus on current or pending legislation. Interest groups can supply their members with well-reasoned arguments in sample letters, but letters are more effective if rewritten in the members' own words. Letters should be as brief as possible while communicating the message in a clear, concise manner. Letter-writing campaigns are more effective if they are used sparingly and selectively. Many indirect lobbying efforts focus on several legislators on a key congressional committee.
Computers are useful for maintaining complex databases with group members' names and addresses and lists of congressional members' committee assignments, special interests, and relationships. Computers can also be used to prompt members of an interest group to send letters to their representatives and can be programmed to send e-mail messages to large numbers of people.
The Internet has become an important hub of lobbying activity where interest groups can post information to members and visitors on their home pages and where members can communicate with each other in chat rooms and through e-mail.
Most interest groups rely on a combination of direct and indirect lobbying strategies. For example, the American Medical Association uses four basic tactics in its lobbying efforts: (a) directly contacting legislators in Washington, (b) providing information to lawmakers in support of favorable policies, (c) engaging in grassroots campaigns, and (d) contributing to campaign funds through its PAC (1, p 186).
Does Radiology Need Lobbying Organizations?
Most physicians were attracted to medicine by the desire to help people and to alleviate suffering. The great majority of radiologists never anticipated a need to be politically active and have had little training in public policy. They have enjoyed successful careers, earning gratitude from their patients and respect from their colleagues and from the general public. Radiology has been one of the most dynamic and exciting fields of medicine over the past 25 years. These are exactly the reasons that we need a lobbying organization.
It is difficult to convince successful groups of the need to mobilize and to effectively lobby to protect and improve their situation. Embattled groups tend to lobby much more effectively (5). In some respects, radiology has become an embattled specialty. Medicare reimbursement and third-party-payer reimbursement are declining at an alarming rate. Insurance companies are motivated to slow the growth of radiology. Turf battles are heating up between radiologists and our clinical colleagues in a variety of specialties. These competitors are aggressive, well financed, politically active, and eager to poach our practices.
Faced with a changing and increasingly complex political environment, radiologists must increase their commitment to help shape health care policy. With potential major shifts in health care legislation looming in the future, radiologists must commit themselves to increased involvement with candidate selection and with the legislative process.
Radiology Advocacy Alliance
The Radiology Advocacy Alliance (RAA) is an organization of diagnostic radiologists, radiation oncologists, and medical physicists dedicated to legislative and political advocacy. The RAA was formed in response to the strategic plan adopted at the 1997 annual meeting of the American College of Radiology (ACR). The strategic plan recommended increased involvement by radiologists in the public policy arena because of the expanding role of government in medical practice. ACR members identified government relations as the organization's top priority in a 1997 survey (13). However, the ACR is prohibited from political activity and substantial lobbying by virtue of its 501(c)(3) status. Therefore, although the RAA was created on the basis of an ACR initiative, it is a separate legal entity. The RAA is a 501(c)(6) organization, which allows it to participate in a wide range of lobbying activities on the state and federal levels.
Historically, the ACR has been the primary public policy advocate for radiologists. The organization's legislative involvement dates back to the radiation protection laws of the 1950s (14, pp 57 and 58). The ACR fought a critical battle on the behalf of radiology in the 1960s as Congress debated over various components of Medicare legislation.
In one proposal under consideration, radiology was categorized as a hospital-based specialty. The so-called radiology-anesthesiology-pathology designation precluded independent fee-for-service radiology practice. The ACR worked closely on this issue with the U.S. House Ways and Means Committee chairman, Wilbur Mills, who advised the group to employ a professional lobbyist. Former Texas Congressman J. T. Rutherford joined the team in this capacity in 1965, and, after an intense lobbying campaign, the ACR was able to avert the radiology-anesthesiology-pathology designation. More recently, the ACR has led successful fights for expanded mammography coverage and for Medicare reimbursement for air-contrast barium enema studies in patients with colorectal cancer.
Despite this history of political victories, current ACR members recognize that additional lobbying capabilities are needed to promote radiology interests. The emphasis in the 1960s was on personal relationships in Washington. However, the legislative process has become more complex, and its potential effect on the health care environment is now more profound.
Health care legislation is often bundled with unrelated proposals in omnibus bills. Coalitions are formed among supporters of the various components of these complex bills, with the result that proponents of one piece of legislation in Congress will back a set of bundled proposals in return for reciprocal support.
The complexity of the policy-making process, along with growing internecine squabbles among competing medical specialties, has highlighted a need for more effective radiology lobbying. No longer is it effective for the ACR to rely solely on establishing relationships with a few congressional committee chairmen. For radiologists to lobby effectively, they must build grassroots support in the communities and states where they can have the greatest influence on members of Congress. This realization led directly to the formation of the RAA.
The RAA currently has about 7,000 members. Membership in the RAA is open to all ACR members. The primary goals of the RAA are (a) to provide information to radiologists about political affairs that might affect their practice, (b) to sponsor seminars and other educational programs on political issues related to radiology, (c) to encourage radiologists to become politically active by supporting favorable candidates or by running for office, and (d) to effectively represent the ACR membership to state and federal government officials.
As a 501(c)(6) organization, the RAA is prohibited from making direct political contributions. However, it is allowed to form a PAC that can sponsor political fund-raisers and contribute money directly to candidates. In March 1999, the RAA formed a national PAC for radiology called RADPAC. This organization's primary purpose is to support pro-radiology candidates at the federal level and to influence legislative issues important to radiologists.
The RAA also provides assistance in establishing and maintaining PACs at the state level. The RAA supports its members' efforts to develop relationships with state and federal policymakers. For example, it will assist its members in planning home fund-raisers for political candidates by providing Federal Election Commission guidelines on limits for contributions and expenditures.
The RAA is funded primarily by voluntary payments by its members. It also seeks financial support from other radiologic organizations with similar interests. Due to its 501(c)(6) status, contributions to the RAA are not tax-deductible.
The RAA provides a vehicle for accomplishing radiology's political aims. It will encourage better political organization and will help to establish, administer, and support PACs at the state and national levels. It will alert radiologists to important political developments and will help them to build relationships with policymakers before political crises arise. The goal is to respond quickly and to present a united front in response to political challenges.
The RAA will help radiologists to further develop relationships already established by the ACR. Many of the contacts on Capitol Hill will still be maintained through the ACR, but the RAA will establish a higher level of activity on the state level and will attain more uniform involvement among states. The underlying motivation for the RAA's agenda should be to secure a political environment that allows radiologists to provide the best possible patient care.
Academy of Radiology Research
The Academy of Radiology Research is another lobbying organization whose primary aim is to increase federal support for imaging research. The Academy, which was established in 1995, is organized as an alliance of the major radiologic and subspecialty medical imaging societies. Its primary focus is to lobby Congress directly to raise the stature of medical imaging research at the National Institutes of Health. The long-range objective of this effort is the establishment of a National Institute of Biomedical Imaging at the National Institutes of Health (15).
Acknowledgments
We thank Melanie T. Young, director of the Radiology Advocacy Alliance, for her helpful comments.
References
This article has been cited by other articles:
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  C. D. Maynard Eugene W. Caldwell Lecture 2007: Radiology Research Good to Great? Am. J. Roentgenol., October 1, 2007; 189(4): 757 - 764. [Full Text] [PDF]
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J. A. Knote Medical Organizational Politics Am. J. Roentgenol., November 1, 2001; 177(5): 1001 - 1004. [Full Text] [PDF]
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