To appreciate fully the role of interest groups in helping to set the policy agenda, it is useful to first consider the role of individual members of American society in health policy agenda setting. In a representative form of government, such as that of the United States, individual members of society, unless they are among the elected representatives, usually do not have the opportunity to vote directly on policies. They do, however, have opportunities to vote on policymakers. Thus, policymakers are interested in what the individual members of society want, even when what they want is not easy to discern.
However, one of the great myths of a democratic society is that its members, when confronted with tough problems such as the high cost of healthcare for everyone, the lack ofhealth insurance for many, or the existence of widespread disparities in health among segments of the society, ponder the problems carefully and express their preferences to their elected officials, who then factor these opinions into their decisions about how to address the problems through policy.
Sometimes these steps take place, but even when the public expresses its opinions about an issue, as illustrated in The Real World of Health Policy: Public's Agenda Differs from President's (see page 174), the result is clouded by the fact that the American people are heterogeneous in their views. Opinions are invariably mixed on just about all health-related problems and their solutions. Public opinion polls can help sort out conflicting opinions, but polls are not always straightforward undertakings. Complicating their use is the fact that on many issues, individuals' opinions are subject to evolutionary change.
Yankelovich (1992) points out that the public's thinking on difficult problems that might be addressed through public policies evolves through predictable stages, beginning with awareness ofthe problem and ending with judgments about its solution. In between, people explore the problem and alternative solutions, with varying degrees ofsuccess. The progress ofindivid-uals along this continuum of stages has a great deal to do with their views on both problems and solutions.
The diversity among members of society, together with the fact that their individual views on important problems and potential solutions to the problems evolve and change over time, explains in large part the tendency of organizations and interest groups to be more influential than individuals in establishing the policy agenda. Interest groups in particular can exert extraordinary power and influence in the political marketplace for health policies, as was discussed in Chapter 3.
Whether their membership comprises individuals or organizations, interest groups are able to present a unified position to policymakers on their preferences regarding a particular problem or its solution by organizing and focusing the opinions of their members. A unified position is far easier for policymakers to assess and respond to than the diverse opinions and preferences of many individuals acting alone. Although individuals tend to be keenly interested in their own health, as well as in the health of those they care about, their interests in specific health policies tend to be diffuse. This stands in contrast to the highly concentrated interests of those who earn their livelihood in this domain or who stand to gain other benefits within the health domain. This phenomenon is not unique to health. Indeed, in general, the interests of those who earn their livelihood in any industry or economic sector are more concentrated than the interests of those who merely use its outputs; these interests are far more concentrated than those of individuals who only incidentally or occasionally interact with the domain.
One result ofthe existence ofconcentrated interests is the formation of organized interest groups that seek to influence the formulation, implementation, and modification ofpolicies to some advantage for the group's members. Because all interest groups seek policies that favor their members, their own agendas and behaviors, as well as their preferences regarding the larger public policy agenda, are often predictable.
Feldstein (2001) argues, for example, that all interest groups representing health services providers seek through legislation to increase the demand for members' services, limit competitors, permit members to charge the highest possible prices for their services, and lower their members' costs of operating as much as possible. Likewise, an interest group representing health services consumers logically seeks policies that minimize the costs of the services to the members, ease their access to the services, increase the availability of the services, and so on. Essentially, this is human nature at work.
Interest groups frequently play powerful roles in setting the nation's health policy agenda, as they do subsequently in the development of legislation and in the implementation and modification of health policies. These groups sometimes play their role proactively by seeking to stimulate new policies that serve the interests of their members. Alternatively, they sometimes play their role reactively by seeking to block changes in public policies that they believe do not serve their members' best interests.
Opportunities to join interest groups are widely available for those who are interested in the policy agenda. As Chapter 3 discussed, individual physicians can join and have some of their interests represented by the American Medical Association (AMA) (www.ama-assn.org). Nurses can join the American Nurses Association (ANA) (www.ana.org). Not only can hospitals join the American Hospital Association (AHA) (www.aha.org), but teaching hospitals can join the Association of American Medical Colleges' (AAMC) (www.aamc.org) Council of Teaching Hospitals and Health Systems; children's hospitals can join the National Association of Children's Hospitals (NACH) (www.childrenshospitals.net); and investor-owned hospitals can join the Federation of American Hospitals (FAHS) (www.fahs.com). Health insurers can join America's Health Insurance Plans (AHIP) (www.ahip.org).
Even subsets of the general population can join a group that seeks to serve their health-related interests. For example, the American Association of Retired Persons (AARP) (www.aarp.org) is a powerful interest group representing the interests of many of the nation's older citizens. Other consumer-oriented interest groups include the Alliance for Retired Americans (www. retiredamericans.org); Families U.S.A. (www.familiesusa.org), which describes itselfas the "voice ofhealth care consumers"; and the Consortium for Citizens with Disabilities (www.c-c-d.org).
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