Let's Make a Deal

Influence: AARP, an organization for people age 50 and over, is one of the biggest players in Washington, and its health-care lobbying team increased from 36 lobbyists at the end of 2008 to 42 in the last quarter. The group has spent more than $9 million on lobbying this year.

Demands: AARP's membership splits evenly along party lines, so the group's main priority has been discussing "the need for bipartisan action."No matter what their political persuasion, however, most older Americans stand to benefit from cuts to prescription drug prices, and AARP is using its lobbying dollars to ensure that they do.

Results: AARP scored a victory when the pharmaceutical industry pledged to halve the rates Medicare recipients pay out of pocket for prescription drugs once they've exhausted their yearly benefits. The House Energy and Commerce Committee bill also allows the federal government to negotiate prices for drugs purchased under Medicare, which tends to save consumers money.

Influence: America's Health Insurance Plans, the health insurers' lobby, may have a smaller lobbying budget than some of its counterparts, but it wields outsized clout. The group has spent $3.9 million on lobbying this year. Insurers gained some pull by promising to stop certain practices, such as denying coverage based on pre-existing conditions.

Demands: Insurers stand to gain tens of millions of customers under the individual mandate, a provision that will require all Americans to have insurance. (The group argues that the reforms it has proposed will not work if people can choose to opt out of health care altogether.) Any government-sponsored health plan is a deal-breaker.

Results: President Barack Obama has changed since the campaign and now supports a plan that would require Americans to buy health insurance. The provision made it into every bill drafted. And although 
AHIP is not the sole force trying to keep the public option at bay, its opposition has kept reformers on edge.

Influence: In the 1940s, the American Medical Association made universal health care synonymous with "socialized medicine," derailing reform efforts. With more than $8 million in 2009 lobbying expenditures, the AMA overshadows physicians' groups like the progressive National Physicians Alliance, which has no budget to hire lobbyists.

Demands: The AMA would love for Congress to eliminate the sustainable growth-rate formula, which is meant to reduce Medicare reimbursement rates if they outstrip the growth of the economy as a whole. The group also has advocated medical malpractice reform and has qualms about an initiative that would collect data on doctors' success rates.

Results: The House version of reform sought to repeal the sustainable growth-rate formula. The Senate, however, simply waived the cuts for 2010. The Energy and Commerce committee voted to give incentives to states for malpractice litigation reforms like requiring an expert to evaluate the merits of a case before it goes forward.

Influence: The U.S. Chamber of Commerce represents businesses big and small and, over the past decade, has spent more money on lobbying than any other organization. It devotes the most effort to lobbying on trade issues, but its 20-person health-care team ranks third.

Demands: Most of the plans considered by Congress went too far for the chamber. The group would prefer market-based reforms that steer clear of both the public option and requirements that businesses either purchase health insurance for their employees or pay additional taxes.

Results: The Finance Committee's version of the bill does not require employers to provide health care and caps fees for those who 
do not at $400 per employee. The Energy and Commerce bill, by contrast, has employers paying 8 percent of average employee salaries to a health-insurance trust fund.

Influence: The Pharmaceutical Research and Manufacturers of America has spent more than $13 million on lobbying this year, more than any other health-related organization. Last June, the group cut a deal with Obama and Sen. Max Baucus and committed $30 billion to cutting rates for Medicare patients who pay out of pocket for their prescriptions.

Demands: As part of the June deal, PhRMA demanded that the government not haggle over drug prices for Medicare. Along with the Biotechnology Industry Organization, PhRMA also pushed for extended data exclusivity for biologics, drugs developed based on DNA research. And although the group supports research into comparative drug effectiveness, it is careful to say that the results should not limit doctors' choices.

Results: Although Rep. Henry Waxman, in parti-cular, supported government-negotiated drug pricing, Baucus' version of health-care reform stuck to the terms of the June deal. In Waxman's committee, a proposal by Rep. Anna Eshoo that would give companies 12 years of exclusivity on biologics beat Waxman's bill, which offered only five.

Influence: The Service Employees International Union has gone out of its way to make friends with other players. The group joined the Divided We Fail campaign (along with AARP), Americans for Stable Quality Care (with PhRMA and AMA), and the progressive coalition, Health Care for America Now. 

Demands: SEIU's main push is for "affordability," so the group supports "play or pay" provisions that tax employers if they don't provide health care. SEIU also wants a public option but is open to other possibilities.

Results: Four of the five committees working on health care created legislation that required most employers to buy insurance or face tax penalties. The Finance Committee's provision -- the $400 cap per employee -- is weaker.