Arguably, three trade groups have emerged at the center of healthcare system transformation efforts in the U.S.: the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP) and the Pharmaceutical Research and Manufacturers of America (PhRMA). Others weigh in—the American Medical Association, AdvaMed, the American Public Health Association and others—but this trio is widely regarded as the Big Tents under which policy changes are pursued.
Each plays a unique advocacy role in the system, protecting their members’ turf from unwelcome regulation while fighting against restrictions that might limit their growth opportunities. Their focus is their members:
| AHA | AHIP | PhRMA | |
| Members | 5000 hospitals & 43,000 individual members | 125 Health Insurers | 31 Manufacturers |
| Board Composition | 26 (10 female) | 33 (5 female) | 25 (3 female) |
| Revenues (’22) | $138.8 Mil | $78.6 Mil | $568.3 Mil |
| Revenue chg. ’22 v. ‘21 | +7.7% | -7.1% | -6.7 |
| Margin (’22) | $6.6 Mil | $4.7 Mil | $-0.1% |
| Exec Comp % of ’22 Rev | 8.4% | 9.6% | 3.9% |
| CEO (Tenure) | Richard J. Pollack (since 2015, with AHA 37 yrs.). | Mike Tuffin (since Jan 2024)Prior: SVP UHG, APCO | Stephen J. Ubl (since 2015)Prior: CEO AdvaMed, FAH |
| Direct Lobbying ‘23 | $30.2 Mil | NA | $27.6 Mil |
| Total Industry Lobbying 2023 (includes all sources) | $133.3 Mil | $129.3 Mil | $383.7 Mil |
Sources:*Nonprofit Explorer – ProPublicaIndustries IRS Form 990 for 2022, the latest year available • OpenSecrets based on year-end 2023.
Ironically, these Big Tents have much in common:
- All three serve diverse memberships and are highly protective of their Big Tents. But each faces growing intramural pressure from member cohorts that seek special attention–especially their large and highly profitable members vs. the rest.
- All three struggle with the notions of affordability, price transparency, profit, executive compensation and value. These terms appear frequently in their white papers and comment letters but each tent defines them differently.
- All three depend on physicians to fund member revenues: they’re gatekeepers to member patients, referrals and prescriptions. Each Big Tent is focused on advocacy that enables physician interactions upon which member revenues can be sustainable and service disruption minimal. Thus, physician well-being is a concern to the Big Tents.
- All blame factors outside their control for health costs escalation. The health habits of population, over-regulation and U.S. monetary policy are frequent targets. Projections by the CBO of annual health spending of 5.6% through 2032 are justified by the Big Tents as the net result of increased demand and flaws in the system’s incentives, legals protections and funding mechanisms. Each Big Tent is on the defensive about how they address costs and waste, and how their prices enable increased affordability.
- All three spend heavily to influence lawmakers to avoid unwelcome regulation. Their spending for direct lobbying is multiplied by formal coalitions with friendly trade groups, political action committees, high net worth contributors and corporations. Coalition building is a major function in each Big Tent used against swings in public opinion of concern or against pending legislation that threaten member interests.
- All three serve memberships that operate primarily with business-to-business (B2B) business models primarily. Each subordinates ‘consumerism’ to ‘patients, enrollees, and communities’ served by their members. Maximizing consumer (voter) good will and counter-messaging against hostile media coverage are core functions in each Big Tent.
- All three favor incremental changes to the status quo over transformational reform of the system top to bottom. Wholesale change is unwelcome though the majority of U.S. adults say it’s fundamentally flawed and needs a fresh start.
In each campaign cycle, the Big Tents create playbooks based on possible election outcomes and potential issues they’ll confront. Each identifies possible political appointees to key government posts, committee appointments and legislative staff that with whom they’ll deal. Each reaches out to friendly think-tanks, ex-pats from previous government roles and research organizations to create favorable thought leadership for the talking heads they trust. And each lines up outside lobbyists to augment their staff.
The Boards of the Big Tent trio weigh in, but senior staff in each of the Big Tents drive the organization’s strategy. They’re experienced in advocacy, well-paid and often heavy-handed in dealing with critics.
Operationally, the 3 Big Tents have much in common. Strategically, they’re far apart and the gap appears to be widening. Each blames the other for medical inflation and unnecessary cost. Each alleges the others use unfair business practices to gain market advantages. And each thinks their vision for the future of the U.S. health system is accurate, complete and in the best interest of the public good.
And none of the three has put-forth a vision for the long-term future of the U.S. health system. Protecting the immediate interests of their members against unwelcome regulatory changes is their focus.
P.S. It can be argued that the American Medical Association is the Fourth Big Tent. However, fewer than a fourth of the million active practitioners are AMA members contrasted to the other Big Tents. Like the trio, AMA’s primary advocacy focus is its members: protecting against encroachment by non-physicians, maintenance of clinical autonomy, restrictions on the use of artificial intelligence in patient care and Medicare reimbursement rate changes are major concerns. And, akin to the others, the wider set of issues facing the system i.e. structure, funding, ownership, price transparency, workforce modernization et al. has gotten less attention.
HENRY KOTULA 