Q: How much influence do lobby groups, healthcare groups, and pharmaceutical companies have in this discussion over what to do with the new health care plan?

A: I think that they have quite a lot of influence, and part of that is due to the fact that they are intrical players in providing health care. And so anytime you're going to reform health care, they are looking to be involved either in implementing that in some way, or that it's going to affect the reimbursement they receive for services they provide. So they have a strong interest in being involved. And I think that anytime some one is reforming health care, [the politicians] want to know what those people think about things. You think hospital associations play a big role because they have special concerns about what's wrong with the current system and what needs to be done, and they are going to be directly affected by any health care reform that we have. So the groups that represent health care providers, you would need to know what those groups think, because that will really determine the success of the reform.

Q: Do you think that the pharmaceutical companies and the other lobbies...do they have too much influence over politicians?

A: Well that's sort of the central question in studying public policy and it's...At some level it's just up to individual judgment as to whether or not you think it's too much influence. Because right there, that's a judgment call as to whether or not...how much influence a pharmaceutical company should have. There's definitely cases where people have argued that those people have too much influence. Recently, the Federal Drug Administration, for example, came out saying they have received what they said they felt was inappropriate pressure from members of Congress from a company who produced a knee replacement joint, and they felt that if the members of the FDA approved that device, but now they're coming out saying they did this with inappropriate influence from members of Congress and that those members of Congress have received campaign donations from the group that makes this device. Now the members of Congress say they would have done that without pressure anyway because the right thing was to approve the device. And so...it's a judgment call as to whether or not you think something's having too much influence. So you have to have a baseline for voters to decide how much influence they think is appropriate.

Q: Do voters acknowledge in general the influences of lobbyists groups and outside organizations and donors to politicians?

A: Well in general, if you want to influence politics, you have to be an organized group. Individuals acting alone really can have a big impact on politics. So in some say, I think everybody...I think that's just part of the way the democracy works. Where there's a concern is if some groups or some voices are not being heard because they lack the resources to organize or they have the inability to organize. And some of the groups have a lot more resources because they represent people from higher incomes and also business groups. And there have been a lot of studies of interest group environment, and it's pretty clear that there are a lot more privileged groups than groups representing the average voter. And so when you're talking about health care, there's not as many groups representing the uninsured as there are groups representing health care providers, pharmaceutical companies, and those types of groups. So the people who would probably benefit most from health care reform are not as organized. I mean, there are public interest groups that represent them, but they're not as prevalent and they don't have as many resources. From a normative perspective, that's where the concern might be if you feel like those voices are not being heard in health care reform.

Q: Do you think that it should be more of a concern on the behalf of the people that perhaps their interests aren't being met as opposed to the interests of these people higher up with more money?

A: It's hard to sort of say 'What kind of system is the best?' because health care systems very. So our health care system is 'the best' in many ways. Our system is the worst in many other ways. And it's sort of how we...what kind of health care system we feel we should have. Do you want to have a system that provides more universal coverage but maybe cuts back on the higher-end types of treatment or one that is our current system which is if you reach age 80, you've got the best health care system you could possibly have. I mean, it's amazing what kinds of things we have available. So those are really sort of normative judgments about 'How should the society distribute resources, and what's the best way to sort out health care dollars?' I think most people will agree that our health care is much, much, much too expensive, and I think that some people would argue that it's due to the fact that it's hard to cut costs because of the pressure of interest groups. Any time you try to cut Medicare, for example, you're going to have to deal with interest groups that represent the elderly, who are pretty politically powerful. And so it's a daunting task to cut the costs of Medicare because cutting costs usually tends to mean that somebody is receiving less of something, it makes it very difficult in the system to reduce costs because there's always going to be groups arguing against that reduction because they don't want their members to experience and reduction. And who should experience those costs - that's really a decision that's based on normative views on how healthcare should be distributed in America.

Q: There have been several major bills that have worked their way through the legislature recently, just in the last ten years or so. And when it's something really substantial like this...a huge push for the administration or Congress, or parts of Congress at least...Is there a concern that once each person's different influences get into the bill that too much is going to be cut out of it?

A: Yes. In the sense that a lot of social programs are not designed very effectively or efficiently because they are usually the result of compromise of many different groups that want different things in the final program. And if you look at even the proposals that are out there right now for health care reform...they're very complicated. And part of that is because there are so many different interests that people are trying to accommodate, that by definition makes it very complicated to change a program. The government has been trying to pass universal health care since 1950, and so each time we pass, it's very challenging to get it through. Even something like Social Security Disability, which is a cash-assistance program to provide for people who cannot work because of a physical disability or a mental disability...that took many, many years to get through, and it's cobbled together. Its structure is very inefficient in that you've got state government involved even though it's a federal program, and it's very complicated. Much more complicated than if you said 'I'm going to sit down; I'm going to design the most effective system that can solve all of our problems.' You can probably map out a blueprint that would make it very easy to develop something that was more effective, but once it goes through the legislative process...it's like watching sausage get made. Lots of complicated things get added in, and people who oppose the program want to structure in a way that actually makes in ineffective. And so you often times will have reforms which people at the end will be like 'Well, why did they adopt a program that does all these complicated things?' And often times the reason is because they're trying to accommodate and compromise. And so one of the big issues is you know, 'Do we have a public option or not?' They may decide to have these 'health care cooperatives' which are sort of like a public option but not exactly, as a form of compromise. But that's not the probably...that just makes it more complicated in a sense because you're bringing in a lot more actors that are involved. Now some people maybe prefer that; they want the least amount of government as possible. But certainly, the system is going to end up being more complicated if they go the route of the not-for-profit cooperatives kinds of things as opposed to a public option. So definitely, you're going to end up with a system that is much more ineffective than if you had a dictator sit down and map out a blueprint about what would be the most effective way to implement a health care system.

Q: So is the nature of our system of democracy inefficient, or is it all these other powers that have their say in the system in Congress who aren't necessarily the Congress people that makes it inefficient?

A: We certainly have a huge amount of interest groups and a lot of organizations that are involved. In something as big as health care, it's huge. It affects so many different people that there are definitely lots of interests. It might be more complicated than in another country where you have less campaign contributions that may free up elected officials to maybe try to enact programs that are more effective. That being said, I think more people would prefer ... A lot of people prefer, I mean a lot of voters prefer our more complicated policies. In the administratively easy thing, universal health care...the Canadian plan. That's probably the most simple, easy way to understand way of reforming health care. But a lot of people are ideologically opposed to having the government involved in that way. And so the alternatives then become something more complicated because you've got government involvement but you've also got private sector involvement so that just by nature, it gets more complicated. Another example would be we have services providing for social benefits through tax expenditure. You get a tax break for buying your home; you get a tax break for a variety of things that other government provide through direct benefits like social services. Guaranteed loans for example, that's a complex system, and maybe is more inefficient, but at the same time, you've got less government control. It's more of a hybrid model. In the end, some people argue the less government, the more effective because the government is inherently inefficient and because there's more competition.

1314 It would be great to see what our policy would look like if you took the interest groups out of it, but we can't do that. We can't see the universe without interest groups. And so there's lots of smoking guns where you think there's been influence, like the FDA I was telling you about, that sounds suspicious that there was some influence because they gave money to the campaign, but how do you know those officials wouldn't have behaved that way had they not had those campaign contributions. So it's impossible to know for sure, it's more of a smoking gun than direct evidence.

Q: So from a politician's standpoint, when you're being elected every 2, 4, 6 years, when your campaign is being funded by certain industries, certain companies, certain other people, do you feel more pressure to appease those people than to appease your constituents?

A: At the bottom line, I think that people have to worry about appeasing their constituents if their constituents are paying attention, and that that issue is really important to them. The constituents are not always vocal about something. As an elected official, if there's someone that has contributed a lot of money to a campaign, what you'll definitely do is listen to them. You may not vote that way, but you'll definitely be exposed to what information they have and you will talk with them. You won't find politicians who will admit that 'Oh yeah, if someone gave me money, I'll have to appease them.' They will never say that. You'd have to be inside of their head to know, or get somebody to do a survey of foreign politicians or something. But it's hard to know that at what point does the fact that you're more likely to have an elected official see the information you have about a possible scenario about being able to talk to them about it. It's hard to believe that it has no impact on how that person views that policy issue, it's hard to say that it doesn't affect what kinds of issues the politician thinks are important problems to act upon. But it's not as clear cut as a quid pro quo 'Oh, you give me money and that definitely means that as an elected official I'll do what you want' It's much more subtle than that. Campaign contributions give you access to politicians, and that access allows you to provide your information to politicians. Policy issues are pretty complicated, and we like to say that 'Oh definitely we should adopt health care reform that looks like this.' But usually, there's different pros and cons of every different type of policy solution. And so it seems like if interest groups are able to get their interests out there and also communicate to an elected official that there's people who really care about the issue, that they're more likely to pay attention to it. And that's why I said that if you're an individual who wants to influence public policy, you have to be organized. You're not going to get very far in trying to influence things if you aren't networked in with other interest groups. The best way to change policy is to form a group and then try and influence it. Then the concern becomes 'Are there some voices that aren't heard?' Which there's some evidence that that's the case.

Q: Tell me about Political Action Committees that are being formed by these Congressmen, Senators, and are turning into these massive funding operations involving other legislators.

A: Politicians do raise money for other politicians, and the reason they do that is that helps them influence other members in Congress. Especially parties. If you want to develop relationships with other people in Congress, one way you can do that is to help raise money for them. Barack Obama travels around trying to help Democrats win Congress. He wants to do that so that they have a good relationship with him, and it's hard to know. Does that mean they're going do everything he says? No. But it certainly doesn't hurt, and it certainly make sit more likely that they're going to have a good relationship with him.............. In order to get things through, you need to have people to work with you on something.

Q: Is there ways for individuals to have their word without necessarily being directly affiliated with these people?

A: Certainly, by giving money to a PAC, you can get around some of the limits. If you a give money to a group that's not advocating for an elected official, that's not helping them with a campaign but is helping them with an issue, it's unlimited how much money you can give. And so you see lots of advertisements on television that are funded by those types of groups. And those commercials are basically trying to affect how the public views a particular issue. And that can make a big impact on the policy. So if you can through providing information and promotions and things like that get more information out, you're more likely to see how more voters feel about an issue and so that could put a lot of pressure on a member of Congress. And so that can be pretty effective, especially when you're trying to oppose change. Because it's a lot easier to stop change than it is to change something, change legislation. And so, if all you're trying to do is stop reform, if you can get a large amount of constituents to get upset about an issue and call into a representative, you are having an impact. You need a lot of people to contribute to that PAC, but it certainly is an effective way to affect public policy.

Q: What comes next for this health care bill now that Baucus has put it out there, and now amendments are getting thrown in here and there, and little different parts added on? What sort of things are going to happen between the different groups to change this bill. Do you think that going into 2010 that it might still be something that we're working on?

A: I've gone back and forth on this health care thing. History is against anything passing right, the evidence...we've been trying since 1950. And it's interesting how Obama tried a totally different strategy than what Clinton tried, but he's run into trouble with his strategy. Clinton tried to come up with that top-down, fill in all the details then give it to Congress, and then Congress can vote on it. And that failed miserably. Now we tried 'let's let Congress come up with whatever they want' That's the Obama administration's approach. Now there's a lot of opposition abound that's pretty apparent and it's hard because of the economy. With a good economy, it would be a lot easier to pass something. The problem with health care is that our health care system is too expensive. Across the board, you're not going to find a policy analyst or a politician who would say that our current rate of spending on health care is something we can continue. We can't. We have to do something to cut costs. And cutting costs is painful. Some people are going to have less than they have currently. Some people might get more. There's a whole lot of uninsured that will get more. But there's certainly...the cuts have to come from somewhere. And so the fact that it's not tenable to spend the amount we're spending increases the likelihood that something will pass, but I think it's going to be a reform that is complicated and has a lot of different aspects to it because it's trying to appease a lot of groups. Also, I think the Democrats truly want some bipartisan support. Now they may not get that, and maybe it's politically better off for them to do something rather than doing nothing, And I don't know. I wish I had a crystal ball and could tell. There's times that I think 'Oh yeah, there's for sure something that will pass,' because as more and more employers stop providing health insurance, there's going to be more and more people dissatisfied with our current health care system. And there's going to be more people active in politics that are more middle class that are unhappy with our health care system. And the fact that the costs...we can't continue them. Ultimately, I think we are going to end up with some health care reform, what we end up with, I'm not sure, and whether it's going to be this year, I don't know. I would say if the economy is doing better, there would be a greater likelihood

Q: Is there anything else you would like to add?

The question of the influence of lobbyists is one that's difficult to answer because it's so hard to provide evidence that a campaign contribution results in an activity. And it's also hard to measure what influences are excluded from the agenda because we don't know what Congress are even considering because there are not interests groups that are pushing that issue. So it's very difficult to empirically answer what the influence is. And I think we have good interest on the amount of interest groups, but I think we need to know a lot more about being able to demonstrate , even though I think most people if you asked , I think most people would be willing to bet 'Of course it matters, how could it not? Why would they do it?' You know that's sort of the question. The empirical evidence just isn't' there to say definitively what kind of influence they're having. I think it's a very interesting question, but one that's very hard to answer.