As healthcare issues remain close to the top of the nation's domestic political agenda, advocacy organizations in Washington are always looking for ways to gain an advantage in getting their point across. One effective strategy is relying on grass-roots lobbying by having members contact senators and representatives directly.
To better understand who wins and loses at this game, I interviewed 77 congressional staff assigned to health policy issues during the spring and summer of 2003. I asked them to look at a list of 171 interest groups working on health policy and identify which ones are "especially well-organized in (their) district or state."
The American Hospital Association received the most mentions from staff, with 64 of 77 staff identifying it as having strong organization at the district or state level. The AHA was followed by, in order, the American Medical Association, AARP, the American Cancer Society and the National Breast Cancer Coalition.
There are at least four major factors behind the AHA's success. First, hospitals have significant natural advantages in the advocacy process. Every congressional district is served by at least one hospital. Hospitals are both important providers of care and large employers. The heavy dependence of hospitals on public programs, such as Medicare and Medicaid, helps local board members appreciate the importance of political involvement and advocacy. Because hospitals bring together the interests of consumers, business and labor, politicians from both parties are responsive to their needs.
A second reason for the AHA's success is that it effectively facilitates communication among its members and its national office. As a representative of a state hospital association explained, "AHA does an outstanding job in communicating with us. They keep us in the loop on a daily basis through e-mails and advisory letters. We find out first from AHA, not from the newspapers."
Effective communication allows the AHA to avert clashes over divergent interests within the organization. For example, when it became obvious that rural hospitals would be big winners during Medicare reform in 2003, it was necessary for the AHA to keep urban hospitals from feeling cheated. It did this by carefully communicating political events in Washington to its members.
The effectiveness of this strategy is demonstrated by the fact that urban hospitals stuck close to the party line. For example, a representative of a prominent teaching hospital told me, "We understand that the rural hospitals get extra attention because of the composition of the Senate. If we think that our interests are not being represented in the long run, however, we will complain. In the future, we will say, `Remember how we dealt with rural issues before.' "
In many organizations, formal structures get in the way of effective communication. But for the AHA, its organizational structure is a third major reason it is successful at the grass roots. Its multilayered structure includes constituency sections (to address special needs, such as rural hospitals, children's health and long-term care), ad hoc task forces and 52 affiliated state hospital associations (including the District of Columbia and Puerto Rico).
Perhaps the most innovative part of the AHA's organization is its regional policy boards. The AHA used to be governed by a Congress-like House of Delegates, as is common in large membership organizations. However, Michael Guerin, the AHA's senior vice president and secretary, explained that the regional boards replaced the House of Delegates in 1996, which had become an outdated way of bringing members together. Members found that regional meetings were a better forum in which to voice their concerns, so the organization decided to switch to regional policy boards as the principal mechanism for members to contribute to the AHA's policy-making process.
Various state representatives with whom I spoke agreed on the desirability of the regional boards. One representative speculated that "although different types of hospitals have different interests, I think the national office keeps everybody together because of the regional meetings."
The unanimous decision by the AHA's House of Delegates to replace itself with a better system of governance is exceptional in the association world. Too many associations are locked into outdated models of organization because of fondness for tradition.
A fourth reason that the AHA has been effective is that it works in harmony with other hospital trade associations. Mary Grealy, president of the Healthcare Leadership Council, said: "When I was at the Federation (of American Hospitals), we used to work closely with AHA because we knew they had a vast grass-roots network by virtue of being the larger association. We encouraged our members to join AHA to make sure that we had a voice for the investor-owned hospitals in the association."
A vice president of another leading national hospital association told me that "We are able to focus so clearly on (our issues) in part because AHA does the hard work on general hospital issues. I can imagine that if there were no AHA, I would be able to devote less of my time narrowly to (our issues)."
The AHA's broad grass-roots network puts it in a strong position to serve as a leader in healthcare policy-making. Yet the notion that hospitals might serve as brokers for the public interest does not sit well with everyone. A lobbyist for a prominent medical specialty society scoffed at the idea, interjecting that "I don't think anyone from within the system can be tasked with fixing it."
Michael Heaney is a doctoral candidate at the University of Chicago and a fellow at the Centennial Center of the American Political Science Association.