Participation in the political process by special interest groups often brings to mind the unpopular image of hard-nosed lobbyists wining and dining legislators. Media reports of the thousands of dollars spent by political action committees (PACS) further contributes to the general mistrust of influence groups.1 Some contend that they contribute to political gridlock, reduced accountability of government,1 and incoherent policies.2 The recent failure to pass a health reform bill in the 103rd Congress can be traced to the activities of special interests. Yet the value of special interest groups as a means of participating in the policy-making process should not be overlooked particularly with regard to policies affecting children. Because children cannot vote, they do not have their own voice in the political arena. They must rely on the efforts of special interest groups to bring their needs to the public debate, educate legislators about their needs, and mobilize sufficient grassroots support to help approve favorable policies and defeat harmful ones. Pediatricians, through the organized efforts of the American Academy of Pediatrics (AAP), have a long and successful history of representing children in the political process. This article discusses the role of special interest groups in representing children in the democratic process. Examples of the AAP's advocacy efforts on behalf of children will illustrate how pediatricians can effectively contribute to the development of child health policy.
ROLE OF SPECIAL INTEREST GROUPS
Historically, special interest groups or factions have been an integral part of the American democratic process. In the Federalist No 10, James Madison proclaimed the inevitability of factions and described them as such:
By a (action, I understand a number of citizens, whether amounting to a majority or minority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.3
Madison advocated limiting the power of factions by promoting competition among them and building an elaborate system of procedural "checks and balances" to curb the potential power of any one group.1 In De Tocqueville's observations of American government during the 19th century, he noted the abundance of political interest groups. He wrote, "In no country in the world has the principle of association been more successfully used or applied to a greater multitude of objects than in America."4
Contemporary political scientists contend that special interests are essential to politics and policy mainly due to the increased complexity, size, and specialization of government.1 Since the early 1960s, the formation of interest groups has accelerated rapidly.5 Today, interest groups number in the thousands. Whether they truly provide for adequate representation of public interests is a continuous debate. Those who subscribe to the theory of pluralism, which assumes that the countervailing centers of power will produce policy that represents the diversity of public interests and needs, believe that special interest groups serve the democratic process well.6 Others argue that interest groups dominate the policymaking process and that the pursuit of their own agendas (usually economic) does not necessarily serve the public interest.7
Yet in the case of children, who cannot vote or otherwise advocate for themselves, special interest groups play an important role in representing children's interests. They raise policy-makers' awareness of children's problems and propose policy solutions. Child advocates also provide the expertise needed to address the unique needs of children in public policy discussions. Furthermore, they can mobilize grassroots support to promote or oppose policies that respectively benefit or harm children. As the multitude of other special interests attempt to influence legislators throughout the formulation of public policy, a group to lobby on behalf of children is essential to protecting their interests.
Child advocates are unique among special interest groups because they generally enjoy a high degree of trust among policy makers. Since most of their lobbying efforts do not focus on their own economic gain, they are relieved of the burden of the perception of self-interest. The resulting credibility enhances their effectiveness in influencing policy.
AMERICAN ACADEMY OF PEDIATRICS' ADVOCACY EFFORTS
The American Academy of Pediatrics has served as an advocate for children since its inception. The organization's mission statement pledges to assist infants, children, adolescents, and young adults in attaining optimal physical, mental, and social health.8 A 1994 survey of the membership found that pediatricians remain dedicated to this mission. Overwhelmingly, respondents identified advocacy as the number one priority of the AAP. The dedication of the organization to its advocacy mission for children and the associated credibility that is perceived by legislators and other decision makers may account fot much of the Academy's success in the political arena.
Academy members participate in advocacy activities for children at all levels of government. At the federal level, the Academy employs full-time lobbyists to represent children's health needs in Congress and before federal regulatory bodies. A grassroots network of pediatricians across the country aids in communicating with members of Congress and their staff.
To influence the affairs of state government, each independent chapter of the Academy has a state legislative chairperson. More than 75% of the chapter presidents describe their chapter as actively involved in state legislative and regulatory activities. About one third of the state chapters employ their own lobbyist (mostly the larger states), and the others rely on the volunteer efforts of pediatricians. Pediatricians also have been successful in influencing policy for children at the local level - through city councils, county commissions, and school boards. However, this discussion will focus on the organized efforts of pediatricians through the AAP at the federal and state levels.
HOW PEDIATRICIANS FACILITATE THE REPRESENTATION OF CHILDREN'S HEALTH NEEDS
Bringing Children's Health Issues to the Policy Debate
There are several ways in which pediatricians as a special interest group facilitate the representation of children's health needs in the policy making process. First, pediatricians play a major role in conveying the salient child health issues to decision makers and the public. Public awareness campaigns and the education of policy makers are leading activities of the national AAP and its state chapters.
In 1989, when serious discussions about the growing number of uninsured Americans were just beginning in Congress, the Academy held a retreat with national policy experts to design a strategy to guarantee health insurance for all children. Children, who comprise one third of the uninsured population, were not a major focus of the original policy debate. Attention was on the needs of senior citizens and catastrophic insurance overage. Over the next 5 years, the Academy and other child advocates kept the problems of uninsured children before the public through a public education campaign, the introduction of the Children First proposal,* and lobbying efforts. Through these efforts, the needs of uninsured children eventually became a recognized part of the much larger health-reform debate. Although health reform legislation foiled toward the end of 1994, the needs of children remained prominent throughout the deliberations in Congress. During the debate on the floor of the Senate, the only amendment to receive bipartisan support was a measure to mandate preventive care coverage in private insurance plans.
At the state level, pediatricians have been successful not only in bringing a child health issue to the attention of legislators but also in convincing legislators to adopt policy to address the issue. Children carrying guns in schools is a growing problem in all communities across America. To raise the associated health and safety consequences before legislators, the North Carolina Pediatric Society and the North Carolina Child Advocacy Institute held a legislative symposium on the issue of guns and schools just prior to the convening of the 1993 state legislature. The authence included legislators, school administrators, health-care professionals, child advocates, and the press. A larger authence was reached through local television coverage and articles in local and state capital newspapers. During the session of the state legislature, pediatricians lobbied intensely for a bill to ban guns in and around public and private schools. Although the direct impact of the pediatricians' lobbying efforts is impossible to measure, it is likely that they contributed to the passage of the prohibition of guns in schools law that was enacted during the 1993 legislative session.
Providing Expertise on Children's Health
With the myriad of issues legislators are expected to vote on each year, they have come to rely on special interest groups and their lobbyists for reliable technical information.9 As experts in child health and development, pediatricians can serve as a valuable resource to legislators on policies affecting children. The Academy often is called on by legislative staff and governmental agencies to provide testimony on children's health issues.
Prior to December 1987, all-terrain vehicles (ATVs) were, for the most part, completely unregulated by the Consumer Product Safety Commission. During 1987, the Academy testified several times before Congress on the hazards of ATVs for children in an attempt to force the Consumer Product Safety Commission to take regulatory action. Specifically, the Academy provided expert opinion on the developmental ability of a child to operate an ATV. Their testimony stated that children under the age of 16 years lack the physical coordination, reflexes, maturity, and judgment to operate an unstable machine weighing between 250 and 500 pounds.10 The Academy's sincere interest in protecting children has made the organization a credible and reliable source. Their testimony likely contributed to the Consumer Product Safety Commission filing a lawsuit against ATV manufacturers in December 1987. The complaint sought to declare ATVs as imminently hazardous consumer products. Unfortunately, this action did not result in regulating the use of ATVs by children to the extent recommended by the Academy. The lawsuit was settled by a consent decree in which the manufacturers agreed to a ban on the sale of three-wheeled ATVs and to undertake a public awareness campaign to inform consumers of the risks inherent to operating an ATV.
Pediatricians also have had unexpected opportunities to educate policy makers about the health-care needs of children. In 1992, the Iowa legislature enacted a law that directed the state insurance commissioner to write regulations requiring insurance companies to cover well-baby care (ie, coverage to age 2 years). The Iowa Chapter of the Academy learned of the law just prior to its passage. However, once enacted, the chapter worked closely with the insurance commissioner's office to write the regulations. The chapter explained the value of preventive care for children, particularly the importance of immunizations, to the insurance department staff Upon learning from the pediatricians that children would not have coverage for the bulk of their immunizations since the regulations were only going to require coverage to age 2, the insurance staff recommended that the authorizing law be changed during the next legislative session so that insured children through age 6 could receive appropriate preventive care. During the 1993 legislative session, the department of insurance recommended and actively supported a bill that amended the original legislation to cover well-child care through age 6. Working with the insurance department, the Iowa Chapter supplied data to convince legislators of the value and low cost of pediatric preventive care. As a result, the original statute was amended to cover well-child care through age 6 during the 1993 legislative session.
In addition to the traditional activities of testifying and lobbying, pediatric expertise also can be infused in the policy process by influencing political appointments. When pediatricians or others supportive of child health issues are nominated for high-ranking positions within the federal government (eg, surgeon general and assistant secretary of health), the Academy, through various channels, supports and tries to persuade the Senate to confirm the appointment.
Another related avenue for pediatric input on behalf of children occurs when the government, at either the federal or state level, appoints advisory boards or committees to oversee the functioning of a government program. While the responsibilities and power of advisory bodies vary, they are often given the authority to approve activities, budgets, and expenditures of government agencies. Advisory in name only, many federal advisory boards, in practice, are vested with die authority to set program priorities and control funding.11 Advisory boards thus provide special interest groups an opportunity to influence public policies made within the executive branch of government. At the federal level, the Academy has submitted recommendations for the membership of various advisory committees such as the National Vaccine Advisory Committee and the US Advisory Board on Child Abuse and Neglect. Pediatricians also sit on numerous advisory committees at the state level such as medical care advisory committees (oversight for Medicaid), pediatric emergency medical advisory boards, and maternal and child health advisory committees, which make recommendations about the expenditure of block grant funds.
Mobilizing Grassroots Support
Once a proposal has been introduced within a legislature, the pressures from countervailing interest groups converge on policy makers. Each group tries to influence legislators to vote in a way that favors their group's position. Legislators have many pressures that influence their votes including partisan politics, personal preferences, and campaign contributions. Because most legislators are interested in reelection, their constituents' recommendations about a bill are generally very influential. Letters, telephone calls, and faxes to legislators from the grassroots get legislators' attention. Pediatricians can assist in reaching legislators by either mobilizing constituent support directly among the members of the AAP or in collaboration with other interest groups.
In August 1993, when the Senate was considering President Clinton's proposal to provide vaccines free of charge to all children, several conservative senators opposed the creation of an entitlement program and were determined to limit the program to needy children by requiring a means test. In order to save the original intent of the program, which was to facilitate the immunization of more preschool children by eliminating economic barriers and allowing all children to receive vaccines in their medical home, the Academy grassroots network was alerted. Pediatricians contacted their congressmen around the country to encourage them to vote against the amendment that would severely limit the scope of the program and put the burden of means testing directly on the physicians who administer childhood vaccines. Although the pediatricians' message was heard and means testing was dropped, a compromised position was adopted in the Omnibus Budget Reconciliation Act of 1993. Medicaid eligible, Native American, and uninsured children would be included in the federally funded program, which was subsequently named the Vaccines for Children Program.
The Academy also has been successful in mobilizing support for child health policy by working in coalitions with other child advocacy groups. For example, pediatricians have worked closely with the National Coalition to End Corporal Punishment in Schools since its beginning in 1987. The coalition's public education activities and advocacy efforts to enlist the support of local parent and teacher organizations has been effective; between 1987 and 1993, 18 states banned corporal punishment in schools.
Unique among medical organizations, the Academy has entered into a formal partnership with another child advocacy organization, the National Association of Child Advocates (NACA). Working together at both the national and state tevels, this partnership was created to improve children's access to health care. The partnership in New York State between the pediatricians and the state affiliate of NACA (Statewide Youth Advocates) demonstrates the power of two child advocacy groups working collaboratively. Their efforts to bring children's issues before the state legislature have resulted in the expansion of Medicaid eligibility for pregnant women and children, the creation of a state-financed children's health insurance program, and higher reimbursement for pediatric services.
As a politically vulnerable constituency, children rely on special interest groups to represent their needs in the political process. The selfless intentions of child advocates give them added credibility that most other special interest groups do not enjoy. This integrity may account for at least part of the success of child advocacy groups such as the American Academy of Pediatrics. Pediatricians have served as agents of change regarding child health policy. They have effectively influenced the selection of children's issues addressed by government, the development of public policies affecting children, and the implementation of federal and state programs for children. Special interest groups may not always serve the public interest, but those who advocate on behalf of children at least provide a voice for an underrepresented special interest.
The author thanks Steven B. Dolins, PhD, for his help in organizing this paper, and James G. Pawelski and Samuel S. Flint, PhD for their critical review.
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