NAHU’s Legislative Influence in Context

This blog attempts to addresses health care reform issues of interest not just to brokers, but to a broader audience as well. This post, however, is aimed at brokers only.

Most brokers are disappointed with the Patient Protection and Affordable Care Act. The list of complaints are long, but would include the impact of the medical loss ratio provisions on their livelihood, the failure to deal with rising medical care costs, and a host of issues related to the exchanges.

Brokers fought hard to make health care reform meaningful, to assure it constrained costs and increased access. On some issues we succeeded. On too many we lost.

Brokers are angry with the result and, understandably, are looking to understand the cause. Sometimes its not enough to identify who won. Blame needs to be apportioned. And a surprising number of brokers, albeit a distinct minority, are blaming their own professional association, the National Association of Health Underwriters.

NAHU can defend itself from the specific charges being leveled (and I invite them to do so here on the blog). But if we’re going to spend time on a discussion of what NAHU could and couldn’t accomplished, then let’s have an informed discussion.

For example, I often hear brokers demand that NAHU educate Americans concerning the value of brokers. Ironically, this is a job each and every broker can do simply by doing their jobs in a professional, effective and visible way. But the context that’s missing from this criticism is the enormous cost such an undertaking would involve.

Then there’s the political battles. NAHU is apparently expected to win them all. But here’s a a quick quiz to explain why this might be harder than some believe. In considering your answers, it might be helpful to remember the adage of then-California Assembly Speaker Jesse Unruh that money is the mother’s milk of politics:

Given a political fight, who is more likely to be heard in Congress, Association A spending over $144 million on lobbying or Association B with a total budget – for everything it does – of less than $6 million?

Who is more likely to win a legislative battle, Association B with it’s $6 billion total spending budget or Association C with a mere $22 million lobbying payout?

Would it change your mind if Association B had a Political Action Committee with roughly $300,000 versus Association C’s contribution to federal candidates totaling more than $17 million?

When it comes to influencing Congress, the US Chamber of Commerce is the king of the hill. The Chamber spent over $144 million on lobbying activities in 2009 and another $132 million in 2010. No one else came anywhere close.

With over 225,000 dues-paying members, the American Medical Association is both a grassroots and a financial power. The AMA contributed over $27 million to federal candidates in the 2010 election cycle and spent $22.5 million on lobbying.

NAHU is the one with the $6 million budget (which also covers member educational activities and the like) and the PAC contributions totaling in the low hundreds-of-thousands-of-dollars.

Some other interesting numbers:

The Service Employees International Union spent over $1.7 million on campaign contributions in the 2010 campaign cycle, down from over $2.8 million for the 2008 election.

In the 2008 election cycle alone, the pharmaceutical industry contributed over $26 million to federal candidates.

Of the top spending lobbying efforts in 2009 according to OpenSecrets.org:

  • #1, as noted, was the Chamber of Commerce at $144.5 million
  • #4 was the Pharmaceutical Research and Manufacturers of America at $26.1 million
  • #5 was Pfizer Inc. at $25.8 million
  • $6 was the Blue Cross Blue Shield Association at $23.6 million
  • #7 was AARP at $21 million
  • #9 was the AMA at $20.7 million
  • #12 was the American Hospital Association at $18.3 million.

You get the idea.

The ability of these organizations to devote these resources to advocating for their members is because those members provide them the resources to do so. What resources NAHU has comes from the same source.

NAHU will never be in the league of $20 million lobbyists. Nor does it need to be. NAHU’s influence is far greater than its lobbying expenditures or the size of its PAC would suggest. It may not have the tens-of-millions of dollars necessary to run a national public education campaign, but it has educated lawmakers and regulators about the role of brokers. We did not win the fight on the medical loss ratio, but that battle continues and the loss would have been harsher, but for NAHU.

There are probably more than 100,000 brokers in this country who earn significant revenue from the sale and service of health insurance. Fewer than 25,000 are members of NAHU. That is a travesty, especially since many of the organization’s most vocal critics are numbered among those contributing nothing to the effort. Standing on the sidelines and criticizing is easy, often unhelpful, but easy.

So here’s the context: NAHU’s size is small relative to many of the other players. And here’s the reality: NAHU’s influence is much larger than its size. NAHU’s done much with relatively little. It could do more with more – more members, more revenue, more PAC contributions.

Asking tough questions of the association’s leadership is appropriate and helpful. If your not a member, letting the organization know why, in a professional manner, can be very helpful feedback. Seeking changes to its direction is the right of any member – non-members deserve and get no voice in determining the organization’s future.

So I am not suggesting in any way that criticism of NAHU is wrong. But to be constructive, the complaints need to understand the scale and scope of the political context in which NAHU operates.

Making Health Care Cost Reduction Promises Real

Representatives from insurance companies, doctor groups, hospital organizations and the pharmaceutical industry had their moment in the presidential sun on May 11th promising to slow down how quickly medical care costs increase. Their promise: $2 trillion in savings over 10 years. That would not only make it more affordable to provide coverage for the uninsured, it would be a huge boost the economy and to the financial condition of state governments.

In a letter signed by, among others, the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, America’s Health Insurance Plans and the Service Employees International Union, which, as the Los Angeles Times described it “shepherded the agreement.” The unprecedented agreement among these health care stakeholders is meaningful for two reasons. First, these organizations were among the leading opponents of the Clinton Administration’s failed health care reform effort in the 1990s. Second, if it’s real, we’re talking about serious money.

And there’s the rub: is it real? President Obama is trying to find out. He’s instructed the organizations to come back to White House with specifics on how it will make this pledge real. As the Administration has demonstrated with the business plans demanded of the auto industry, the White House will hold these interest groups to a high standard. Which it should. The political stakes are high. If the cost cutting plans lack credibility President Obama will look, as the Associated Press noted, he “will be seen as naive for entertaining such promises.”  By holding them to a high standard, however, President Obama also has the power to undercut the industries’ opposition to his health care reform plan. Accusing them of insincere promises and inadequate commitment to cost cutting would bolster those who seek a bigger role for government in any new health care system.

The stakeholders have an equally important political task. By coming forward with voluntary, credible proposals for cutting costs, they provide political cover for those opposing the expansion of the government’s involvement in the system. If their proposals pass muster they will have gone a long way toward morphing from being a target of reform to being a part of the solution.  Their specifics for cutting costs will be part of the health care reform legislation Congress will produce this summer, which means they’ll have to live with them. But if that means the forthcoming legislation is a bit friendlier to their interests, that’s a reasonable price to pay.

Fortunately, the target, while a stretch, is eminently doable. Researchers at Dartmouth University have done several studies over the years that demonstrate that high costs for medical care do not correlate with better outcomes. As the Associated Press reports, they found that “as much as 30 cents of the U.S. health care dollar could be going for tests and procedures of little or no value to patients.”

One person who paid attention to this finding is Peter Orszag, Director of the Office of Management and Budget. As I wrote in 2007, when he was Director of the Congressional Budget Office, Mr. Orszag was “pushing for more evidence based assessments of new technologies and the need to expand research on comparative effectiveness. They key, Mr. Orszag indicated, is to provide new incentives in the system aimed at changing provider and consumer behavior.” His goal: to eliminate the $600 billion in “wasteful or low-value services” currently in the system.

If health care reform is going to work, squeezing this $600 billion out of the system is crucial. The associations’ efforts are an important first step. According to the Associated Press article, the groups are focusing on different aspects of the problem. Insurers, for example, are looking at reducing administrative costs by, among other initiatives, establishing a common, shared on-line claim form doctors and patients could use. Doctors are looking at establishing guidelines for medical practice. Improving information on drug interactions and reducing hospital readmissions are also part of the mix.

Most experts agree that the savings are there to be found. Identifying the savings will require political will and a willingness to change “business as usual” in the medical, pharmaceutical and insurance industries. Whether they pass the test will be determined by President Obama. Having shared the stage with him to make the promise, the price of failure will be extremely high.