Throughout this year I've spent quite a bit of time looking at the connections between powerful players in the health care debate and their former staffers turned health care lobbyists. The reason to highlight these connections is simple: it shows how outside organizations get the ear of key lawmakers.

You and I can't hire a the former chief of staff to Senate Finance Committee chairman Max Baucus, but America's Health Insurance Plans (AHIP) can. Nor can we hire Sen. Blanche Lincoln's former chief of staff, but a dozen health care companies can. These people have connections that worth more than gold in Washington. They have the ears of the players in Washington.

Roll Call did some more reporting on this and brought us some crucial information on these lobbyists. In particular, I'd like to point to one relationship that I've written about more than once. That's Sen. Blanche Lincoln's former chief of staff Kelly Bingel. Here's a visualization that we created showing Lincoln's connection to Bingel. And here's what Roll Call has to say:

In the case of key fence-sitter Sen. Blanche Lincoln (D-Ark.), Mehlman Vogel Castagnetti lobbyist Kelly Bingel is said to have the ear of her former boss. Bingel declined to be interviewed for this article, but a former colleague called her “first on the list” of the Senator’s callbacks.

...

“She’s Sen. Lincoln’s alter ego,” a former colleague said.

Organizations with a stake in legislation know that the best way to get the attention of lawmakers is to poach their most connected, most knowledgable staffers and hire them as lobbyists. The ordinary constituent can't call up a senator and lobby them on a policy issue, but their close buddy and former employee can. Just look at this quote from the Roll Call article:

"It is helpful. We have lines of communication open,” a lobbyist and former Senate Democratic staffer said. “We have access to lay out our argument.”

Without that access you can't get anything done.

(Most of our coverage of health care lobbyists and the revolving door can be found here.)

TPM is reporting that Majority Leader Harry Reid is going to exclude a provision that would remove the anti-trust exemption for health insurers from the Senate health care reform bill. The move is apparently being made to grease the gears for Sen. Ben Nelson, one of three Democratic hold-outs, to vote for procedural motions in the run-up to a final vote. The provision was a huge fear of health insurers, particularly of America's Health Insurance Plans (AHIP) and Blue Cross Blue Shield. Both of those organizations are represented by former staffers to Sen. Nelson and fellow hold-out Sen. Blanche Lincoln.

As documented in this post from two days ago, Sen. Nelson's former legislative director now lobbies for three top health insurers: Blue Cross Blue Shield, Aetna and UnitedHealth Group. Sen. Lincoln's former top health adviser Elizabeth Barnett lobbies for the same three health insurers. Kelly Bingel, Sen. Lincoln's former chief of staff, lobbies for AHIP. Since 2005, Blue Cross Blue Shield has contributed over $80,000 to Sen. Lincoln and over $65,000 to Sen. Nelson.

Blue Cross Blue Shield is the largest provider of health insurance in both senator's states. In Arkansas, Blue Cross holds a 75% market share and UnitedHealth Group is second with 6% market share. Blue Cross' market share in Nebraska is 44% and UnitedHealth Group has a 25% market share. In both states, the removal of the anti-trust exemption could cause serious loss of market share for these companies.

The exclusion of the provision to remove the exemption would be a big win for these former staffers turned lobbyists. Not only did they get what their clients wanted, but the utility of their connections has been publicly touted.

The provision to remove the health insurer anti-trust exemption was included in the House bill and supported by President Barack Obama. It was used by the House and the White House as a stick to keep the health insurance industry from waging a public campaign of opposition. When the industry finally decided to publicly oppose the bill, the provision was included in the final House legislation.

The New York Times reports that there are three Democratic senators who are viewed as holdouts on a procedural vote to go forward with debate on the final Senate health care reform bill. The senators are most conservative members of the Democratic caucus and represent states that largely voted for Republicans in both the 2004 and 2008 presidential races. They also are all top recipients of campaign contributions from the health insurance industry and have former staffers working for the industry.

From 2005 to 2009, Sen. Blanche Lincoln has received $139,149 from the health insurers and HMOs. The majority of that money comes from Blue Cross Blue Shield, the health insurance provider that holds a 75 percent market share in the senator's home state of Arkansas. Blue Cross Blue Shield has contributed over $80,ooo to Sen. Lincoln since the 2006 election cycle.

Elizabeth Barnett, Sen. Lincoln's former health advisor, left the senator's office in 2007 to work as Blue Cross Blue Shield's top Democratic lobbyist. Earlier this year, Barnett left Blue Cross to work for Avenue Solutions, where she retains Blue Cross Blue Shield as a client. Avenue Solutions’ profile of Barnett notes that she “had primary responsibility for representing [Blue Cross Blue Shield] and its 39 member plans before the Senate Finance Committee, Senate Democratic Leadership, and other key Senate committees and offices.” Barnett also represents the two other major health insurers UnitedHealth Group and Aetna.

(You can see a visualization of Sen. Lincoln's connections to health care companies through her former staffers turned lobbyists here. This was created for a previous post on Sen. Lincoln.)

In 2005, Sen. Lincoln's chief of staff Kelly Bingel left to work for Mehlman Vogel Castagnetti Inc. with a lobbying portfolio that includes over a dozen clients invested in health care reform. Bingel represents a who’s who of the health care industry including America’s Health Insurance Plans (AHIP) and Pharmaceutical Researchers & Manufacturers of America (PhRMA). While AHIP previously refused to take sides in the health care debate, in the past few months the health insurers group has voiced a full-throated opposition to the public option and has taken on the administration and Congress over the overall bill. PhRMA, on the hand, received a sweetheart deal that was crafted by Sen. Max Baucus and the White House that won their support of the entire bill.

Sen. Ben Nelson of Nebraska is third Democratic holdout. Since the 2006 election cycle, Sen. Nelson has received $91,200 from health insurers and HMOs. Like Sen. Lincoln, the majority of that money comes from Blue Cross Blue Shield with $65,550 coming from the largest health insurance provider in the senator's state.

Sen. Nelson's former legislative director Amy Terjal left his office in 2007 to work as a lobbyist at Avenue Solutions, the same firm as Barnett. Terjal holds the same clients as Barnett. Three of the top health insurers in the nation -- Blue Cross Blue Shield, UnitedHealth Group and Aetna -- are clients of Terjal's.

Another Democratic holdout, Louisiana's Sen. Mary Landrieu received $104,548 from health insurers and HMOs since the 2006 election cycle. Sen. Landrieu's long time chief of staff Jason Matthews (1996-2009) left her office this year to work as director of congressional affairs for the U.S. Chamber of Commerce. The Chamber is a staunch opponent of health care reform recently commissioning a study to prove that the stated health care reforms being considered in Congress would have a negative economic impact.

Health insurers had remained on the sidelines of the health care reform debate until recently. In October, AHIP released a study that claimed to show the cost of health insurance plans rising in the years following the enactment of reform. Since then, the organization has begun running television commercials in at least 10 states threatening seniors that their benefits will be cut under the reforms under consideration in Washington.

Earlier today, Majority Leader Harry Reid held a closed door meeting with these three senators to assuage their concerns and court their vote on cloture for the health reform bill. Sen. Nelson released a statement that appears to show support for voting in favor of cloture on the bill, "Why would you stop senators from doing the job they're elected to do -- debate, consider amendments, and take action on an issue affecting every American?"

Today, President Obama held a public event with a number of leading health industry trade associations that have previously been reticent towards efforts to reform health care. The organizations included the Pharmaceutical Researchers and Manufacturers Association (PhRMA), America's Health Insurance Plans (AHIP), the American Medical Association (AMA), the Advanced Medical Technology Association (AdvaMed) and the American Hospital Association (AHA). The public event included a promise by these industry groups, among others, to reduce health care costs by $2 trillion. It also served as a symbolic event, potentially showing the shrinking rift in between the two sides in the health reform debate. President Obama wants these organizations to temper their fire when the health reform debate begins in full, as they wield a mighty hand in the Washington lobbying game.

1st Quarter Lobbying
PhRMA	$6,910,000
American Medical Assn	$4,355,000
American Hospital Assn	$4,237,176
America's Health Insurance Plans	$2,030,000
Advanced Medical Technology Assn	$364,638

In their first quarter reporting for 2009, these five trade associations have reported  nearly $18 million in lobbying expenditures. Their expertise in reaching out to Congress is also nearly unparalleled. The five trade groups employ in their inside lobby shops at least 20 former government employees, many of whom are former congressional staffers. The head of PhRMA's lobby shop is former congressman Billy Tauzin, notorious for negotiating his current job as he was writing Medicare prescription drug benefit while in Congress. (This does not take into account the outside lobbying firms hired by these groups.)

The health care sector, on the whole, is leading the pack in lobbying expenditures this year. After three months of 2009, the sector has reported $127 million in lobbying expenditures. That is on pace to break the record $487 million spent by the sector on lobbying in 2008 and the congressional debate has yet to be fully engaged. The sector is the only other private sector that competes with the financial sector in lobbying spending. From 1997-2008, the health care sector has spent $3.4 billion on lobbying officials in Washington -- only slightly less than the financial sector ($3.6 billion). There are varying views in the health care reform community on whether this public event will help President Obama's reform effort or if it will empower the industry groups to be able to squash the pieces of reform they deem unacceptable. Jonathan Cohn, Marc Ambinder and Paul Krugman believe that this is a net benefit for reform advocates. Cohn writes, "[E]very day that these groups are saying positive things about reform in public is day they're not saying nasty things about reform in public." The American Prospect's Ezra Klein, on the other hand, takes a more cautious approach, stating, "The fact that the White House is making a big deal of their support means it would be a big deal if they lost it."

But Klein also notes that the real fight won't occur until an actual bill is dropped, which will happen in June. When the next lobbying disclosure reports come out on July 20th, we'll be able to see how much these groups are engaged in the debate. These groups have the ability to spend massive amounts of money and that is the only metric we will have to measure their lobbying campaign when the next round of disclosures are released.

We won't, however, be able to see who in Congress, or the administration, they are contacting and for what goals they are aiming. Without disclosure of contacts, it may take some time for the President and supporters and opponents of reform to see whether today's event was just a high-level photo-op, or if it actually paid off in one-way or the other.