Sarah Dorsey on the Sunlight Foundation Reporting Group site posted yesterday about the continued health care reform lobbying.

Her post also included infographics breaking down some aspects of the 1,000-plus health care reform waivers that have been granted to businesses, unions, and cities and towns. Here's her description of the waivers:

While many of the act's major changes have yet to take effect, the administration has already exempted more than 1,000 groups from one of its requirements: the mandate to provide at least $750,000 in annual coverage per enrollee. About 2.6 million individuals with so-called "mini-med" plans are affected by these waivers.

The exemptions last for only one year, and are scheduled to be phased out in 2014, when states will be required to operate exchanges -- marketplaces where individuals can purchase coverage. The waivers are designed as a temporary stopgap to prevent beneficiaries from being dropped from coverage or priced out of it.

While small businesses were among those given the reprieve this year, including Captain Elliot's Party Boats, with 10 enrollees, and Hoosier Stamping and Manufacturing Corp., with 14, waivers were also granted to huge insurance companies. Aetna received an exemption for plans that cover over 209,000 enrollees, and Cigna's waiver affected 265,000.

The majority of those waivers have gone to employers and plans with under 500 enrollees. Here's the graphic showing the breakdown by type of organization receiving the waiver:

And here's the view by number of enrollees:

This, of course, does not show whether the smaller number of 5,000-plus enrollee plans contain the majority of the number of individuals granted waivers through the waiver program.

Read the whole story and see other graphics on the current lobbying on health care reform at the Sunlight Foundation Reporting Group site.

The pharmaceutical industry is beginning to wade into the 2010 midterm elections in support of those that helped to preserve a deal crafted by the White House to secure the industry's support for the health care reform bill that President Barack Obama signed into law in March.

The first advertisements are appearing in support of Senate Majority Leader Harry Reid, according to The Washington Examiner's Tim Carney.

Here's the ad:

In 2009, the White House met with leaders from the pharmaceutical industry and their lobbyist in Washington to determine what could be done to get the industry to support the administration's health care reform efforts. Ultimately, a deal was reached whereby the drug companies would support the bill through advertising and lobbying and the White House and Congress would ensure that cost-savings extracted from the industry would not top $80 billion or include certain provisions including the re-importation of drugs and providing Medicare with negotiating authority over prescription drug plans. (For the full story on the deal click here.)

Reid successfully shepherded the health care reform bill, with the pharmaceutical industry deal intact, through the Senate despite criticism coming from different wings of the Democratic Party.

Throughout the process Reid mobilized Democrats to block efforts to alter the terms of the deal between the White House and the pharmaceutical industry.

In the Senate Finance Committee, three Democrats sided with Republicans to block an amendment that would have fully closed the donut-hole in Medicare Part D prescription drug coverage.

When the bill came to the floor for a vote Reid successfully whipped Democrats to vote against an amendment that would have provided for the re-importation of drugs from first-world countries, a provision that Democrats had long supported and campaigned on. The amendment failed with many Democrats voting against it.

Reid has received more than just television advertising support from the pharmaceutical industry. According to the Center for Responsive Politics, Reid has received $361,850 in campaign contributions from the pharmaceutical industry over the course of his career.

Fifty-four percent of that total--$198,450--came from contributions made in 2009 and 2010.

As the Examiner's Carney points out, Reid is the second leading recipient of pharmaceutical campaign contributions for 2009-2010. A large number of the contributions were made around the time of key events in the crafting of the deal between the White House and the drug companies.

PBS' Frontline is running an investigation into the various negotiations and deals that led to the formation of the health reform bill that is now law. The program should be incredibly informative and not just because it features yours truly. The program is called Obama's Deal and runs next Tuesday (April 13) at 9 PM on your local PBS station. I've embedded a preview of the program that focuses on the insurance industry. If you've been following our health care coverage or simply care about the health reform overhaul, this will be must watch television:

Concessions to the pharmaceutical industry were added to the reconciliation bill after the industry agreed to provide additional savings requested by President Barack Obama. According to the Associated Press, Senator Max Baucus stated in an interview that the pharmaceutical industry agreed to provide an additional $10 billion to cover the coverage gap in Medicare Part D known as the "donut hole" in exchange for eliminating the expansion of drug discounts at certain health facilities initially included in the Senate health care bill.

The Senate health care bill would have expanded drug discounts under a Medicaid program that serves over 14,000 covered facilities. The Medicaid 340B program provides outpatient discounts on brand name drugs to a variety of health facilities that serve low-income communities. The provision removed in the reconciliation bill would have expanded access to the discount program to cover inpatient drug purchases. While the inpatient expansion was eliminated in reconciliation, an increase in the kinds of covered health facilities remained.

Last year, the pharmaceutical industry negotiated a behind-the-scenes deal with the White House and Sen. Baucus to limit the savings sought from the industry in the health reform bill to $80 billion. The deal involved the White House and Baucus to not pursue long-sought-after Democratic policies including allowing the government to negotiate for lower drug prices in the Medicare drug program and the reimportation of drugs from first world countries. The pharmaceutical industry would, in return, support the legislation through advertising and grassroots means. The industry ultimately spent upwards of $100 million on advertising to support passage of the legislation.

The extra money to fill the "donut hole"--a coverage gap in the Medicare prescription drug program--was proposed by the White House in the run-up to the Blair House Summit. The Washington Post reported at the time that industry lobbyists were not enamored with this new proposal, "PhRMA, which agreed to $80 billion in cuts in exchange for protection from other steps, has concerns about Obama’s proposal to add another $10 billion to that amount."

The industry had already beaten back the expansion of the 340B drug discount in earlier negotiations with the House of Representatives. The initial Tri-Committee House health care reform bill contained the same expansion that was included in the Senate bill, but was removed in November when the final version of the legislation was introduced and voted on. At the time, other industry leaders voiced their concerns over the exclusion of the expansion of coverage. The American Hospital Association (AHA) stated that the discount should be added to the bill later on: "Lawmakers also should restore a provision that would expand the outpatient 340B drug discount program to inpatient services for all eligible hospitals."

The Congressional Budget Office (CBO) projected that the expansion of 340B drug discounts to inpatient services would save hospitals $1 billion annually and Medicaid $1.7 billion over ten years.

From the 1990 election cycle to the 2008 election cycle the health sector contributed over $829 million to candidates for federal office and political parties. Over the course of those 19 years Congress debated comprehensive reform of the health sector, passed a Medicare drug benefit, made various changes to Medicare and Medicaid and established and expanded access to the Children's Health Insurance Plan. A review of campaign contributions made available by the Center for Responsive Politics indicates that control of Congress, and the power exerted by that control, has been a key determinative factor in the party distribution of contributions by the health sector over the years.

Beginning in the 1990 election cycle, Democrats received a slightly larger share of health sector contributions than Republicans, despite the Republican Party's pro-business positions. This spread stays the same through the 1992 election, which included the election of the Democratic President Bill Clinton. Clinton's push for comprehensive reform of the health sector in 1993-94 and the industry's opposition to such reforms began to push their campaign contributions towards the Republicans. In 1994, Republicans surpassed Democrats in health sector contributions and retook both chambers of Congress.

The health sector didn't look back after 1994 giving overwhelmingly to the Republicans in Congress and their presidential nominees. While the previous three election cycles (1990, 1992, 1994) were all very close in the health sector contribution distribution between the parties, the 1996 election saw a full 60% of health sector contributions go to Republicans seeking office. This wide divide only increased over the years.

(Click the play button on the graphic below to see a visualization of the change in health sector contributions to the parties from 1990-2008. I'd advise selecting unique colors under the Color tab.)

The elections of 2002, 2004 and 2006 provided for the biggest health sector contribution disparities between the parties. In each of these elections Republicans pulled in over 60% of the health sector contributions to federal candidates and parties. The highest percentage came in the 2002 election cycle as Congress began to debate the inclusion of a prescription drug benefit within Medicare. In this election Republicans received 65% of health sector contributions. The resulting legislation, passed in 2003, wound up very friendly to the pharmaceutical industry. So friendly, in fact, that the chief author of the legislation, Rep. Billy Tauzin, left Congress and quickly signed on as the President and CEO of the industry's Washington lobby shop, the Pharmaceutical Research and Manufacturers of America (PhRMA).

Over the next two election cycles the industry faced a Republican Party that was largely supportive of their interests--and had recently enacted legislation that they widely supported--and a Democratic Party that sought to enact sweeping reforms of the industry and seek further cost savings from the pharmaceutical industry in the new Medicare prescription drug plan. Facing this decision, the industry stayed with the party that controlled both the Congress and the Executive Branch--the Republicans. The industry gave 62% of their campaign contributions to Republicans in the 2006 election cycle despite the overwhelming evidence of imminent Democratic victory. Majority control and the nature of the Democrats' campaign proposals kept the industry alongside the Republicans.

The 2006 election swung control of Congress to the Democrats for the first time in 12 years and with that came a major swing in campaign contributions from the health sector. Contributions shifted rapidly away from Republicans as Democrats stepped up to head the committees that would oversee and write legislation related to the health sector. The health sector had to also account for the unpopularity of the Republican Party and President George W. Bush. With almost every political prognosticator predicting another sweep for the Democrats, including the White House, the health sector had to prepare for the coming attempt to pass comprehensive health care reform, the holy grail of Democratic policy goals.

The health sector dramatically shifted their contributions from Republicans to Democrats in the 2008 election cycle. Democrats received 54% of all health sector contributions, the highest percentage they have received since the Center for Responsive Politics began tracking campaign contributions. Leading the way was presidential candidate Barack Obama. Obama, perhaps the largest recipient of health sector contributions in history, brought in over $19 million from the sector in the 2008 election cycle.

While the above graphics do not show 2010 health sector contributions the disparity between the parties has only grown. Democrats have received 58% of all health sector contributions. Republicans have fallen to their lowest percentage in recorded history. And the contributions did not come without benefits. The health sector was brought close into the discussion on comprehensive health care reform. The pharmaceutical industry, the hospital industry and doctors all signed onto legislation and helped to ultimately pass comprehensive reform. The final product included many concessions to these and other industries and cut out many long-standing Democratic policy priorities that the industries feared.

Last year, I looked at the instances of the word "Internet" in the Senate version of the health care reform bill. Now that the Affordable Care Act is law it is worth reviewing this again. Nearly all instances of the word "Internet" in the law refer to online disclosure of information, data, reports and studies. The use of the word "Internet" increased from 66 in the Senate bill to 75 in the final law. For the most part the uses remain the same as those referenced in the post covering the Senate bill. Here's what I wrote then:

The Department of Health and Human Services would be required to post nearly every report filed with the Department online. These reports range from information ensuring the quality of care provided by insurers to information meant to control premium increases. The various Internet disclosure provisions include new information on hospitals, hospice care and long term care facilities. New web sites would be created to provide information on affordable health care options and for the State administered health care exchanges.

Health and Human Services would be tasked with creating an Internet portal template for state administered health care exchanges. The web site template would provide information for individuals and employers to help them determine their eligibility for the exchange. The web site would also be required to present standardized information on the plans made available in the exchange including a rating to inform users to the basis of the relative quality and price of each plan offered.

Another of the bill’s Internet disclosure targets is affordable coverage. The bill tasks Health and Human Services with creating a web site to provide information on affordable coverage in each state. The provisions targets specific types of coverage for this disclosure including private coverage that is not limited to reimbursement for any one disease or condition or an “unreasonably limited” number of diseases and conditions. Other coverage options that must be disclosed and shown to be affordable on this web site include some Medicaid coverage and coverage under S-CHIP. The web site will also include standardized information on each plan including premium rates, cost sharing, premium revenue expended on non-clinical costs, eligibility and availability.

The bill also targets health insurers with a disclosure provision. The bill aims to control what it calls “unreasonable” premium increases by requiring insurers to provide a justification for such increases prior to the implementation of the increase. The justification must be made to the Department of Health and Human Services and simultaneously posted to the insurers web site in a prominent manner that the public can see.

Some online disclosure actions take effect soon. The Department of Health and Human Services must, by April 23rd, publish on their web site a list of all new authorities granted to the Department's Secretary under the law. By July 1st of this year Health and Human Services must create, or facilitate in the state-creation of, an Internet web site to help people identify affordable health care options. In creating this site the Department must develop standardized formats for this information. These standardized formats must be completed by May 23rd of this year. Within one year of enactment the Department must create an Internet portal for the state level health care exchanges and create a template for state-level exchange web sites. These web sites will be required to disclose all costs of the exchanges as well as a wealth of information about the various health care plans available. The provision requiring health insurers to disclose and justify "unreasonable" premium increases prominently on their web sites begins with the Secretary creating a process, to begin this year, for the annual review and disclosure of such premium increases.

I noticed this post last week from Matt Yglesias dinging Ezra Klein on the power of interest groups in light of the health care reform debate. Yglesias wrote:

What happened in the health care debate is that interest groups were able to get their way on most key points without needing to seriously attempt to deliver votes in exchange. The AMA is supporting the bill, but it’s not running ads against opponents. Pharmaceutical companies and insurers haven’t dropped out of the ferociously anti-reform Chamber of Commerce. No interest group that I’m aware of is cutting off the flow of funds to Chuck Grassley to punish him for his role in sabotaging health reform. Nobody is hitting Olympia Snowe for her bait-and-switch. I haven’t read a single story about a single Republican being “in trouble” with supporters for his or her opposition to reform.

Now that the bill has passed, it's pretty easy to say that Yglesias is mostly correct. For-profit industry groups did not need to deliver votes for health care reform, yet they were provided huge concessions in the negotiating stages. Instead of delivering votes these organizations were simply asked to not be destructive and to not oppose the bill. In the case of the pharmaceutical companies, they provided large sums of money for advertising to support the bill, but did little to convince their traditional allies in the Republican Party. In the end, these companies received a huge windfall for little effort on their part and with no need for them to stop aligning with opponents of the legislation. Just look at their campaign contributions.

Consider the pharmaceutical companies, who in cutting a deal with the White House got pretty much all the concessions they wanted. You'd think that they wouldn't just spend money on running ads in favor of the legislation, but they might distance themselves from the anti-reform crowd. As Yglesias pointed out, they didn't leave the Chamber of Commerce, an organization that was matching the pharmaceutical companies dollar-by-dollar in ads opposing the legislation. The pharmaceutical companies also didn't stop sending campaign contributions to members of Congress who were ferocious in their opposition to the bill. The top recipient of pharmaceutical and medical product industry money in Congress during the 2010 cycle is Sen. Richard Burr, Republican of North Carolina. Burr has received $143,319 since the beginning of last year. Other top recipients include Sen. Orrin Hatch ($115,515), Rep. Eric Cantor ($63,000), Rep. Dave Camp ($61,150) and Rep. John Boehner ($60,000). As you might know by now, every Republican voted against the bill in both the Senate and the House. Pharma even gave $70,000 to Rep. Jim Matheson, a Democrat who voted against the bill. The hospitals were more consistent in sending money to supporters of the legislation, but they still continued to contribute to anti-reform lawmakers like Burr ($66,300), Sen. Chuck Grassley ($61,300) and Sen. Richard Shelby ($53,600). (All numbers come from the Center for Responsive Politics.)

More importantly, it's unlikely that any of these groups will be running advertisements for or against lawmakers in the 201o elections. Pharma ran ads to help get the legislation passed because it helped protect them from deeper cost-cuts that Democrats supported and brought them 32 million new customers. Now that it's passed, they might make the calculation that fewer Democrats in office might protect them from future reforms that they beat back in this legislative round. Alliances like those between powerful interest groups and those normally viewed as opponents don't last forever or to the next election cycle even.

The unions, however, certainly demonstrated their muscle as an interest group in Washington with heavy lobbying of lawmakers to support the bill coupled with primary threats across the country. If interest group power were on the wane you couldn't see it when watching the AFL-CIO, SEIU and AFSCME in action. And these are groups that will be running ads for or against lawmakers.

Interest group power is certainly alive and well. There is no doubt about that. It just appears that the more traditional ways in which groups are asked to support legislation--deliver votes, support candidates in the future--were not used in this legislative battle, except in the case of Labor. An ad hoc coalition of for-profit industry groups was formed to not oppose the bill. If anything this path was chosen because these groups are so powerful that even just neutralizing them left enough wiggle room to get the bill passed. In the process, these groups got more than they could ask for.

Check out this line from Jay Newton-Small's Swampland blog post on the way forward for health care reform in the House:

Once they have a bill, Dems need to post it online for at least 72 hours for members to review before a vote.

The fact that reporters covering Congress are stating that the Majority "needs" to post the bill online for 72 hours shows how far the Read the Bill effort has gone. As this policy has become the norm it is increasingly clear how important legislative information is to both individual members of Congress and ordinary people.

Congress should still pass a rules change to require the 72 hours reading time to make the policy enforceable. Still, you've shown Congress that people out there want to be able to read legislation and be assured that their representatives have enough time to read and study the bills.

Seven key Democrats seen as potential vote-flippers on the health care reform bill are heavily reliant on campaign funds from party leadership and online progressive activists.

According to campaign finance data at the Center for Responsive Politics, all seven Democrats--Reps. Jason Altmire, Suzanne Kosmas, Frank Kratovil, Scott Murphy, Glenn Nye, Michael McMahon and Betsy Markey--list Leadership PACs (political action committees) in the top three career industry donors. Three of the seven members are also heavily reliant on money from Democratic campaign committees or outside progressive fundraising through the web site Actblue.

The seven Democrats were identified in an Associated Press survey of members who previously voted "No" on the House health care reform bill. With pressure mounting to pass the Senate's health care reform bill and the resignation of key members along with the death of Rep. John Murtha, Speaker Nancy Pelosi must round-up lawmakers like these seven to vote "Yes" after a previous "No" vote.

The upper Democratic leadership is particularly active in contributing to these lawmakers. Five of the seven lawmakers--Kosmas, Kratovil, Murphy, Nye and Markey--count the PACs of Speaker Pelosi, Majority Leader Steny Hoyer and Majority Whip James Clyburn in their top twenty career individual donors. Rep. McMahon counts two of the three Democratic leadership PACs (Hoyer and Clyburn) in his top twenty.

All of these seven lawmakers are either freshmen or, in Rep. Altmire's case, a sophomore. Freshmen and sophomore lawmakers are often in greater danger of losing their next election and, therefore, more reliant on party and leadership funds to finance their victories. This puts them in a situation where the leadership has significantly more sway over their floor votes than other members.

Similarly, outside activists can push a lawmaker towards a certain vote by contributing or withholding funds. Rep. Scott Murphy, who won a special election in New York to replace appointed-Sen. Kirsten Gillibrand, is the top recipient among the seven lawmakers of money from ActBlue, the online progressive clearinghouse for campaign contributions. Murphy received $315,807 in individual contributions through the ActBlue site making ActBlue his number one career individual donor. Rep. Betsy Markey also received a significant amount of campaign money through ActBlue with $124,090 coming in from the site.

See below for totals:

Lawmaker	Industry	Amount	Rank
Jason Altmire	Leadership PACs	$220,662.00	3rd
Suzanne Kosmas	Leadership PACs	$201,978.00	2nd
Frank Kratovil	Leadership PACs	$182,115.00	3rd
Betsy Markey	Democratic/Liberal	$263,329.00	1st
	Leadership PACs	$229,248.00	3rd
Michael McMahon	Leadership PACs	$168,300.00	2nd
	Candidate Committees	$122,500.00	3rd
Scott Murphy	Democratic/Liberal	$383,017.00	1st
	Leadership PACs	$203,400.00	3rd
Glenn Nye	Leadership PACs	$190,791.00	2nd