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Lobbying Expenditures and Campaign Contributions by the Pharmaceutical and Health Product Industry in the United States, 1999-2018

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Abstract and Figures

Importance Government efforts to lower drug costs and other legislative and regulatory initiatives may be counteracted by campaign donors and lobbyists in the pharmaceutical and health product industry. Objective To review how much money the pharmaceutical and health product industry spent on campaign contributions and lobbying in the US from 1999 to 2018 at the federal and state levels. Design and Setting Analysis of federal-level and state-level data obtained from the Center for Responsive Politics and the National Institute on Money in Politics, respectively. These nonprofit, nonpartisan organizations track federal and state campaign contributions and lobbying expenditures by individuals and groups. Exposures Lobbying expenditures and contributions to political campaigns. Main Outcomes and Measures Total spending, inflation adjusted to 2018 dollars using the US Consumer Price Index, on lobbying and campaign contributions by year, source, and state. Results From 1999 to 2018, the pharmaceutical and health product industry recorded $4.7 billion—an average of $233 million per year—in lobbying expenditures at the federal level, more than any other industry. Of the spending, the trade group Pharmaceutical Research and Manufacturers of America accounted for $422 million (9.0%), and the other 19 top companies and organizations in this industry accounted for $2.2 billion (46.8%). The industry spent $414 million on contributions to candidates in presidential and congressional elections, national party committees, and outside spending groups. Of this amount, $22 million went to presidential candidates and $214 million went to congressional candidates. Of the 20 senators and 20 representatives who received the most contributions, 39 belonged to committees with jurisdiction over health-related legislative matters, 24 of them in senior positions. The industry contributed $877 million to state candidates and committees, of which $399 million (45.5%) went to recipients in California and $287 million (32.7%) went to recipients in 9 other states. In years in which key state referenda on reforms in drug pricing and regulation were being voted on, there were large spikes in contributions to groups that opposed or supported the reforms. Conclusions and Relevance From 1999 to 2018, the pharmaceutical and health product industry spent large sums of money on lobbying and campaign contributions to influence legislative and election outcomes. These findings can inform discussions about how to temper the influence of industry on US health policy.
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Lobbying Expenditures and Campaign Contributions
by the Pharmaceutical and Health Product Industry
in the United States, 1999-2018
Olivier J. Wouters, PhD
IMPORTANCE Government efforts to lower drug costs and other legislative and regulatory
initiatives may be counteracted by campaign donors and lobbyists in the pharmaceutical and
health product industry.
OBJECTIVE To review how much money the pharmaceutical and health product industry
spent on campaign contributions and lobbying in the US from 1999 to 2018 at the federal and
state levels.
DESIGN AND SETTING Analysis of federal-level and state-level data obtained from the Center
for Responsive Politics and the National Institute on Money in Politics, respectively. These
nonprofit, nonpartisan organizations track federal and state campaign contributions and
lobbying expenditures by individuals and groups.
EXPOSURES Lobbying expenditures and contributions to political campaigns.
MAIN OUTCOMES AND MEASURES Total spending, inflation adjusted to 2018 dollars using the
US Consumer Price Index, on lobbying and campaign contributions by year, source, and state.
RESULTS From 1999 to 2018, the pharmaceutical and health product industry recorded $4.7
billion—an average of $233 million per year—in lobbying expenditures at the federal level,
more than any other industry. Of the spending, the trade group Pharmaceutical Research and
Manufacturers of America accounted for $422 million (9.0%), and the other 19 top
companies and organizations in this industry accounted for $2.2 billion (46.8%). The industry
spent $414 million on contributions to candidates in presidential and congressional elections,
national party committees, and outside spending groups. Of this amount, $22 million went to
presidential candidates and $214 million went to congressional candidates. Of the 20
senators and 20 representatives who received the most contributions, 39 belonged to
committees with jurisdiction over health-related legislative matters, 24 of them in senior
positions. The industry contributed $877 million to state candidates and committees, of
which $399 million (45.5%) went to recipients in California and $287 million (32.7%) went to
recipients in 9 other states. In years in which key state referenda on reforms in drug pricing
and regulation were being voted on, there were large spikes in contributions to groups that
opposed or supported the reforms.
CONCLUSIONS AND RELEVANCE From 1999 to 2018, the pharmaceutical and health product
industry spent large sums of money on lobbying and campaign contributions to influence
legislative and election outcomes. These findings can inform discussions about how to
temper the influence of industry on US health policy.
JAMA Intern Med. doi:10.1001/jamainternmed.2020.0146
Published online March 3, 2020.
Editorial
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Author Affiliation: Department of
Health Policy, LondonSchool of
Economics and Political Science,
London, United Kingdom.
Corresponding Author: Olivier J.
Wouters, PhD, Department of Health
Policy, LondonSchool of Economics
and Political Science, Houghton St,
London WC2A 2AE, United Kingdom
(o.j.wouters@lse.ac.uk).
Research
JAMA Internal Medicine | Original Investigation
(Reprinted) E1
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In 2018, the US spent an estimated $3.6 trillion, or 17.6% of
its $20.5-trillion gross domestic product, on health care, in-
cluding $345 billion on prescription drugs sold in retail
pharmacies.
1
Adjusted for inflation, per-person spending on
prescription drugs sold in US retail pharmacies increased from
$520 in 1999 to $1025 in 2017.
2
Although both Democrats and
Republicans consider lowering prescription drug prices a
priority,
3
lobbyists and campaign donors in the pharmaceuti-
cal industry may counteract efforts by federal and state gov-
ernments to decrease these costs.
In the US, citizens and organizations, including corpora-
tions, have the right to petition politicians and elected offi-
cials to try to influence policy decisions.
4
Citizens and orga-
nizations may do so individually or collectively through interest
groups. They can exert their influence through lobbying
(ie, contacts by paid lobbyists with officials or their staff to dis-
seminate information about regulatory or legislative
matters).
4,5
Apart from lobbying, individuals and organiza-
tions may contribute money to political campaigns to sup-
port their preferred candidates and improve their access to suc-
cessful candidates.
6-8
Campaign contributions and lobbying
expenditures differ and are subject to different regulations.
8,9
There is evidence that campaign contributions and lob-
bying expenditures may influence election and legislative
outcomes.
10-15
However, few studies have analyzed such spend-
ing by the pharmaceutical and health product industry,
and most of the research is from 2009 or earlier.
16-22
Prior re-
search has primarily focused on lobbying and campaign con-
tributions by the health care sector as a whole in individual
years at the federal level. Trends over time have received less
attention, as have contributions to candidates and commit-
tees in state elections, where money may be used to influ-
ence the outcomes of referenda on measures aimed at lower-
ing drug costs.
This study analyzed lobbying expenditures and patterns
of election contributions by the pharmaceutical and health
product industry at the federal and state levels from 1999 to
2018.
Methods
Federal-leveland state-level data were obtained from the Cen-
ter for Responsive Politics
23
and the National Institute on
Money in Politics,
24
respectively. These nonprofit, nonparti-
san organizations track federal and state campaign contribu-
tions and lobbying expenditures by individuals and groups.
Both organizations categorized all contributions and ex-
penditures by sector and industry within each sector; the cat-
egories were modeled on the federal government’s standard
industrial classification system. The pharmaceutical and health
product industry includes manufacturers of pharmaceutical
and biological products, diagnostic tests, medical devices and
equipment, and nutritional and dietary supplements as well
as pharmacy benefit managers.
On September 30, 2019, the databases of the 2 organiza-
tions were searched for campaign contributions and lobby-
ing expenditures by individuals and groups in the pharma-
ceutical and health product industry from January 1, 1999, to
December 31, 2018. State-level data on campaign contribu-
tions from January 1, 1999, to December 31, 2002, were in-
complete for some states owing to lack of reporting. As no data
were collected from human participants and the data were pub-
licly available, the study was exempt from institutional re-
view board approval at the London School of Economics and
Political Science.
Federal-Level Data
Data on lobbying expenditures were based on disclosure re-
ports filed with the Senate Office of Public Records. Lobbying
firms are required to provide the office with quarterly esti-
mates of lobbying incomes (rounded to the nearest $10 000)
from clients who spent $3000 or more in a given quarter. Or-
ganizations that hire lobbyists as direct employees are re-
quired to report lobbying-related expenditures to the nearest
$10 000 if outlays were $12 500 or more in a given quarter.
23
The data on election campaign contributions were based
on disclosure reports filed with the Federal Election Commis-
sion. From these reports, the Center for Responsive Politics ex-
tracted all records of (1) cash contributions of $200 or more to
federal candidates and national party committees from indi-
vidual donors and political action committees; (2) soft money
contributions from individuals, corporations, labor unions, and
ideological groups to national party committees; and (3) do-
nations to outside spending groups, which operate indepen-
dently of and not in coordination with candidates’ commit-
tees and can spend money on communications with the public.
Soft money contributions from individuals, corporations, la-
bor unions, and ideological groups to national party commit-
tees are donations that cannot be used to directly support the
election bids of federal candidates but rather fund other ini-
tiatives, such as voter registration drives.
16
In 2002, the Bipartisan Campaign Reform Act
25
banned soft
money contributions but allowed donations to state and lo-
cal political parties for use in activities related to voter regis-
Key Points
Question How much money did the pharmaceutical and health
product industry spend on lobbying and campaign contributions in
the US from 1999 to 2018?
Findings This observational study, which analyzed publicly
available data on campaign contributions and lobbying in the US
from 1999 to 2018, found that the pharmaceutical and health
product industry spent $4.7 billion, an average of $233 million per
year, on lobbying the US federal government; $414 million on
contributions to presidential and congressional electoral
candidates, national party committees, and outside spending
groups; and $877 million on contributions to state candidates and
committees. Contributions were targeted at senior legislators in
Congress involved in drafting health care laws and state
committees that opposed or supported key referenda on drug
pricing and regulation.
Meaning An understanding of the large sums of money the
pharmaceutical and health product industry spends on lobbying
and campaign contributions can inform discussions about how to
temper the influence of industry on US health policy.
Research Original Investigation Lobbying Expenditures and Campaign Contributions by the Drug Industry in the United States
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tration and participation in federal elections, known as Levin
funds. Congress acted in response to concerns that soft money
contributions, which were not subject to federal limits on cam-
paign contributions, were being misappropriated.
16
The 2010
Supreme Court case of Citizens United v Federal Election
Commission
26
(and related court decisions) legalized contri-
butions by corporations and unions to new types of outside
spending groups, including so-called super political action
committees. Prior to the ruling, no donations to these groups
were recorded; the ban on soft money contributions re-
mained in effect.
For each of the 20 senatorsand 20 representatives who re-
ceived the most contributions from the pharmaceutical and
health product industry from 1999 to 2018, records from the
US Government Publishing Office
27
were searched to deter-
mine whether these members served at any point during this
period on a committee with jurisdiction over health-related leg-
islative matters, a health-relatedsubcommittee of one of these
committees, or both.
27
It was also noted if a member served
as chair, vice chair, or ranking member of any of these com-
mittees or subcommittees or held a party leadership position
(Speaker of the House, majority leader, minority leader, ma-
jority whip, or minority whip in the House; president pro tem-
pore, majority leader, minority leader, majority whip, or mi-
nority whip in the Senate). Some committees and
subcommittees changed names over the study period.
For the Houseof Representatives, the committees were En-
ergy and Commerce; Ways and Means; Oversight and Re-
form; Budget; Education and Labor; Appropriations; and Vet-
erans’ Affairs. For the Senate, the committees were Finance;
Aging (Special Committee); Budget; Health, Education, La-
bor, and Pensions; Appropriations; and Veterans’ Affairs.
The subcommittees included in the House were (1) Health
(Energy and Commerce); (2) Health (Ways and Means); (3)
Health Care, Benefits, and Administrative Rules (Oversightand
Reform); (4) Health, Employment, Labor, and Pensions (Edu-
cation and Labor); (5) Agriculture, Rural Development, Food
and Drug Administration, and Related Agencies (Appropria-
tions); (6) Labor, Health and Human Services, Education, and
Related Agencies (Appropriations); (7) Department of Veter-
ans’ Affairs (Appropriations); and (8) Health (Veterans’ Af-
fairs). In the Senate, the subcommittees were (1) Health Care
(Finance); (2) Primary Health and Retirement Security (Health,
Education, Labor, and Pensions); (3) Agriculture, Rural Devel-
opment, Food and Drug Administration, and Related Agen-
cies (Appropriations); (4) Labor, Health and Human Services,
Education, and Related Agencies (Appropriations); and (5) Mili-
tary Construction, Veterans’ Affairs, and RelatedAgencies (Ap-
propriations).
State-Level Data
Data on lobbying expenditures at the state levelwere unavail-
able for most states and thus were excluded from the analy-
sis. However, the National Institute on Money in Politics
24
col-
lects data from all 50 states on campaign contributions from
individuals and organizations in the pharmaceutical and health
product industry to the following state-level candidates and
committees: (1) gubernatorial or other statewide candidates;
(2) house, assembly, or senate candidates; (3) supreme court
candidates; (4) political party committees; and (5) ballot mea-
sure committees. Ballot measure committees raise funds to op-
pose or support ballot measures, which are proposals that are
voted on by the electorate to pass or repeal statelaws or amend-
ments to the state constitution.
28
The National Institute on
Money in Politics
24
acquires the data from various state regu-
latory offices.
Data Analysis
Descriptive statistics were used to report total campaign con-
tributions and lobbying expenditures by the pharmaceutical
and health product industry, with results brokendown by year,
source, recipient, political party,and state. For comparison, ag-
gregated data on federal lobbying expenditures by the top 10
industries and organizations were also collected, as were data
on expenditures by the 4 industries in the health sector in ad-
dition to the pharmaceutical and health product industry (ie,
hospitals and nursing homes, health professionals, health ser-
vices and health maintenance organizations, and miscella-
neous health organizations). Because health insurance com-
panies are grouped with life, property, and car insurance firms,
they were excluded from the health sector for this analysis. Fed-
eral campaign contributions were recorded over 2-year cycles,
reflecting the timing of congressional elections.
All dollar figures were inflation adjusted to 2018 dollars
using the US Consumer Price Index. Stata version 15 (Stata-
Corp) and Excel 2016 (Microsoft) were used for all analyses.
Results
Federal-Level Lobbying Expenditures
From 1999 to 2018, across all industries, a total of $64.3 bil-
lion was spent lobbying Congress and federal agencies in the
US. During this time, the pharmaceutical and health product
industry recorded the highest spending of all industries ($4.7
billion [7.3%]), followed by the insurance industry ($3.2 bil-
lion [5.0%]), the electric utilities industry ($2.8 billion [4.4%]),
and the electronics manufacturing and equipment industry
($2.6 billion [4.0%]). Within the health sector, total lobbying
expenditures were $9.7 billion. Expenditures in addition to
those by the pharmaceutical and health product industry were
recorded by hospitals and nursing homes ($1.9billion), health
care professionals ($1.7 billion), health services and health
maintenance organizations ($1.3 billion), and miscellaneous
health organizations ($139 million).
Pharmaceutical and health product industry spending on
federal lobbying averaged $233 million per year. From 1999 to
2009, annual spending increased, before decreasing briefly and
increasing again (Figure 1). Expenditures peaked at $318 mil-
lion in 2009, the year before the Patient Protection and Af-
fordable Care Act was signed into law.
Over the 20-year study period, 1375 organizations in the
pharmaceutical and health product industry reported lobby-
ing expenditures. Seventeen of the 20 highest spending orga-
nizations were manufacturers of biological or pharmaceuti-
cal products or their trade associations (Table 1). The other 3
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organizations were the Advanced Medical Technology Asso-
ciation (a trade association for medical device companies),
Medtronic (a medical device company), and the Seniors Co-
alition (an interest group that does not disclose its donors and
lobbies for limited governmentintervention in drug and health
care markets). The top spender, the trade group Pharmaceu-
tical Research and Manufacturers of America (PhRMA), ac-
counted for $422 million (9.0%) of the $4.7 billion, and the
other 19 top spenders accounted for $2.2 billion (46.8%).
Across all industries, only 5 organizations reported more
spending than PhRMA: the US Chamber of Commerce ($1.7 bil-
lion), the National Association of Realtors ($602 million), the
American Medical Association ($462 million), the American
Hospital Association ($426 million), and General Electric ($423
million). Following PhRMA, the seventh and eighth ranked
spenders were the Blue Cross Blue Shield Association ($391 mil-
lion) and AARP (formerly American Association of Retired Per-
sons) ($334 million). Thus, 5 of 8 organizations with the larg-
est lobbying expenditures were health care related.
Federal-Level Campaign Contributions
From 1999 to 2018, the pharmaceutical and health product in-
dustry contributed $414 million to federal (presidential and
congressional) candidates, national party committees, and out-
side spending groups (Figure 2). This included $152 million in
contributions from individuals affiliated with the health care
industry, $165 million from political action committees, and
$96 million in soft money contributions and donations to out-
side spending groups.
Excluding contributions to outside spending groups, the
industry donated $367 million to party candidates and com-
mittees ($216 million [58.9%] to Republicans; $151 million
[41.1%] to Democrats), with more money going to Republi-
cans than to Democrats in all but 2 election cycles (2008 and
2010). The 2000 and 2002 election cycles, 2 of 5 cycles with
the highest spending levels, coincided with congressional de-
bates on the introduction of Medicare Part D (a prescription
drug benefit program for seniors) and the 2000 presidential
election. The 2 cycles with the highest spending (2012 and
2016) were presidential election years. The 2018 election cycle
had the fifth highest spending.
Of the top 20 campaign contributors (Table 1), 15 were
manufacturers of biological or pharmaceutical products, and
1 was the trade group PhRMA. The other 4 were Amerisource-
Bergen (a drug wholesale company), D.E. ShawResearch (a bio-
chemistry research company), Pharmaceutical Product De-
velopment (a contract research organization), and SlimFast
Foods (a producerof nutritional and dietar y supplements).Five
pharmaceutical companies were among the top 10 spenders
for both campaign contributions and lobbying: Amgen, Eli Lilly
and Company, Johnson & Johnson, Merck, and Pfizer.
Contributions to presidential candidates totaled $22 mil-
lion. The eTable in the Supplement lists the 20 presidential can-
didates who received the most contributions from individu-
als and political action committees in the pharmaceutical and
health product industry. Of the $19.3 million contributed to
these candidates, the top recipient was Barack Obama ($5.5 mil-
lion), followed by Hillary Clinton ($3.7 million), Mitt Romney
($3.0 million), and George W. Bush ($2.4 million). The next 16
candidates combined received $4.7 million.
Contributions to congressional candidates totaled $214 mil-
lion. Table 2 shows the top 20 recipients, in each chamber of
Congress, of contributions from individuals and political ac-
tion committees in the pharmaceutical and health product in-
dustry.These 40 legislators jointly received $45 million (21.0%)
of all contributions to congressional candidates; 39 were mem-
bers of committees with jurisdiction over health-related leg-
islative matters, and 24 held senior positions in these com-
mittees. Of the 20 members of the House, 17 served on the
Energy and Commerce Committee or the Ways and Means
Committee. Of the 20 senators, 13 served on the Finance
Committee.
State-Level Campaign Contributions
From 1999 to 2018, the pharmaceutical and health product in-
dustry contributed $877 million to state-level candidates and
Figure 1. Federal-Level Lobbying Expenditures by the Pharmaceutical and Health Product Industry, 1999-2018
350
250
300
200
150
100
50
0
Annual spending, $ in millions
Year
200320011999 2007 2009 2011 2013 2015 2017 20192005
Medicare Part D
signed into law as
part of Medicare
Modernization Act
Patient Protection
and Affordable
Care Act signed
into law
2016 Presidential
election, in which
drug pricing was a
key issue Dashed lines indicate key events that
affected the pharmaceutical and
health product industry. Data from
the Center for Responsive Politics.
23
Amounts were inflation adjusted to
2018 dollars using the US Consumer
Price Index.
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committees in 50 states and the District of Columbia, of which
$661 million (75.4%) went to ballot measure committees. The
remainder was contributed to house of representatives, as-
sembly,and senate c andidates ($99 million), state party com-
mittees ($72 million), gubernatorial and other statewide can-
didates ($44 million), and supreme court candidates ($1
million).
Over this period, total contributions exceeded $50 mil-
lion in 2 states, California ($399 million) and Ohio ($74 mil-
lion), and were between $20 million and $50 million in 6
states—Missouri ($43 million), New York ($33 million), Or-
egon ($27 million), Florida ($26 million), Illinois ($23 mil-
lion), and Texas ($22 million). Contributions totaled $10 mil-
lion to less than $20 million in 7 states, $5 million to less than
Table 1. Top 20 Lobbying Spenders and Campaign Contributors in the Pharmaceutical
and Health Product Industry at the Federal Level, 1999-2018
a
Rank Organization
b
Expenditures, $ in millions
Lobbying spenders
1 Pharmaceutical Research and Manufacturers of America 422.3
2 Pfizer 219.2
3 Amgen 192.7
4 Eli Lilly and Company 166.2
5 Biotechnology Innovation Organization (BIO)
c
153.4
6 Merck 143.0
7 Roche Holdings
c
135.9
8 Novartis 130.2
9 Johnson & Johnson 129.9
10 Sanofi
c
116.7
11 Bayer 111.0
12 GlaxoSmithKline 110.8
13 Bristol-Myers Squibb 101.6
14 Abbott Laboratories 96.6
15 Advanced Medical Technology Association 79.4
16 Seniors Coalition 65.3
17 Medtronic 63.8
18 Baxter International 58.4
19 AstraZeneca 54.6
20 Teva Pharmaceutical Industries 53.3
Total 2604.3
Campaign contributors
d
1 Pfizer 23.2
2 Amgen 14.7
3 Eli Lilly and Company 13.3
4 GlaxoSmithKline 12.6
5 SlimFast Foods 11.3
6 Johnson & Johnson 11.2
7 D.E. Shaw Research 11.0
8 Merck 10.6
9 Abbott Laboratories 10.0
10 Bristol-Myers Squibb 7.7
11 Exoxemis 6.9
12 McKesson 6.8
13 Ischemix 5.7
14 Pharmaceutical Research and Manufacturers of America 5.6
15 AstraZeneca 5.4
16 Pharmaceutical Product Development 5.2
17 Schering-Plough 5.1
18 AmerisourceBergen 4.9
19 Sanofi
c
4.3
20 Novartis 4.0
Total 179.5
a
Data from the Center for
Responsive Politics.
23
Amounts
were inflation adjusted to 2018
dollars using the US Consumer Price
Index.
b
Expenditures by subsidiary
organizations were attributed to the
parent organizations. Amounts
included contributions from
organizations’ political action
committees and from individuals.
Companies that merged or were
acquired were treated as separate
entities prior to the transaction.
c
BIO changed its name from
Biotechnology Industry
Organization to Biotechnology
Innovation Organization in 2016;
the figure for BIO included
expenditures under both names.
The figure for Roche Holdings
included expenditures by Roche
Group. Sanofi changed its name
from Sanofi-Aventis to Sanofi in
2011; the figures for Sanofi included
expenditures under both names.
d
Amounts included contributions to
candidates, party committees, and
outside spending groups. These
figures included contributions from
organizations’ political action
committees and from individual
members, employees, or owners of
companies or organizations in an
industry or from their immediate
family members.
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$10 million in 7 states, $1 million to less than $5 million in 20
states, and less than $1 million in 8 states and the District of
Columbia. Candidates and committees in California received
45.5% ($399 million) of all contributions, compared with 32.7%
($287 million) for recipients in the other 9 states with the most
contributions.
Figure 3 shows trends in contributions in the 4 states that
received the most money. Of the $399 million in contribu-
tions in California, $197 million (49.4%) and $123 million
(30.8%) were spent in 2005 and 2016, respectively; in these 2
years, there were 3 ballot measures intended to reduce drug
costs, all of which were rejected by voters.
29-32
In 2005, 1 of 2
defeated ballot measures was Proposition 78, which PhRMA
and pharmaceutical companies supported. In the other years,
contributions in California followed cyclical patterns, reflect-
ing the timing of legislative elections. Of the $74 million do-
nated in Ohio, $61 million (82.4%) was spent in 2017, the year
of a ballot measure aimed at lowering prescription drug costs,
which was voted down.
33
Of the $43 million donated in Mis-
souri, $34 million (79.1%) was spent in 2006, the yearof a bal-
lot measure on the legality of stem cell research, which was
passed.
34
Contributions in New York followed a cyclical pat-
tern in line with the timing of state senate and assembly elec-
tions. Trends in the other 46 states and the District of Colum-
bia generally followed the pattern observed in New York, with
a few exceptions.
Discussion
From 1999 to 2018, the pharmaceutical and health product in-
dustry spent large sums of money on lobbying and campaign
contributions. More than twice as much money was spent on
elections at the state level than at the federal level. Federal cam-
paign contributions were targeted at senior legislators serv-
ing on congressional committees thatdraft health c are bills and
at presidential candidates from both major political parties. At
the state level, the industry focused its efforts on opposing ma-
jor drug cost-containment measures by contributing to ballot
measure committees in key states. Threecost-containment bal-
lot measures in California and 1 in Ohio were all defeated.
30-33
In 2005, PhRMA and pharmaceutical companies supported 1
of the ballot measures, Proposition 78 in California; the propo-
sition, which voters rejected, would have allowed pharma-
ceutical companies to voluntarily provide discounts on drugs
sold to individuals with an income below a threshold.
30
When considering legislative and policy initiatives, Con-
gress and the executive branch benefit from fully considering
Figure 2. Campaign Contributions by the Pharmaceutical and Health Product Industry to Federal (Presidential and Congressional) Elections
by Source, 1999-2018
a
30
20
10
0
Annual spending, $ in millions
Yeare
IndividualsbPACscSoft/outside moneyd
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
PAC indicates political action committee.
a
Data from the Center for Responsive Politics.
23
Amounts were inflation
adjusted to 2018 dollars using the US Consumer Price Index.
b
Contributions from individual members, employees, or owners of companies
or organizations in an industry or from their immediate family members; there
are limits on individual contributions to candidates and national party
committees during elections.
c
PACs pool campaign contributions from members of corporations, labor
unions, and ideological groups and disburse the funds to political candidates
and national party committees; there are limits on PAC contributions to
candidates and national party committees during elections.
d
Soft money contributions (banned as of November 6, 2002) and donations to
outside spending groups and Levin funds. Outside spending groups, which
include so-called super PACs, operate independently of and not in
coordination with candidates’ committees; spending by outside groups is
largely unregulated and unlimited.
e
Each year corresponds to a 2-year election cycle; eg, 2000 refers to January 1,
1999, through December 31, 2000. Presidential elections occurred in 2000,
2004, 2008, 2012, and 2016.
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Table 2. Top Recipients of Campaign Contributions From the Pharmaceutical and Health Product Industry in Congressional Elections, 1999-2018
a
Rank Candidate (party, state)
Contributions received,
$ in millions
b
Active years
Member of health-related
committee
c
Senior member of
health-related committee
d
Party
leader
e
House elections
1 Eshoo, Anna (D, California) 1.8 1993-present Yes
f
No
g
No
2 Upton, Fred (R, Michigan) 1.6 1987-present Yes
f
Yes No
3 Pallone, Frank (D, New Jersey) 1.5 1988-present Yes
f
Yes No
4 McCarthy, Kevin (R, California) 1.4 2007-present No No Yes
5 Paulsen, Erik (R, Minnesota) 1.3 2009-2019 Yes
f
No No
6 Ryan, Paul (R, Wisconsin) 1.3 1999-2019 Several
f
Yes Yes
7 Ferguson, Mike (R, New Jersey) 1.3 2001-2009 Yes
f
Yes No
8 Boehner, John (R, Ohio) 1.3 1991-2015 Yes Yes Yes
9 Walden, Greg (R, Oregon) 1.2 1999-present Several Yes No
10 Shimkus, John (R, Illinois) 1.2 1997-present Yes
f
No No
11 Hoyer, Steny (D, Maryland) 1.1 1981-present Yes
f
No Yes
12 Barton, Joe (R, Texas) 1.0 1985-2019 Yes
f
Yes No
13 Burgess, Michael (R, Texas) 1.0 2003-present Yes
f
Yes No
14 Tiberi, Pat (R, Ohio) 1.0 2001-2018 Several
f
Yes No
15 Dingell, John (D, Michigan) 1.0 1955-2015 Yes
f
Yes No
16 Lance, Leonard (R, New Jersey) 1.0 2009-2019 Yes
f
No No
17 Camp, Dave (R, Michigan) 1.0 1991-2015 Yes
f
Yes No
18 Johnson, Nancy (R, Connecticut) 0.9 1983-2007 Yes
f
Yes No
19 Cantor, Eric (R, Virginia) 0.9 2001-2014 Yes No Yes
20 Kind, Ron (D, Wisconsin) 0.9 1997-present Several
f
No No
Total 23.7 NA 19 12 5
Senate elections
1 Hatch, Orrin (R, Utah) 2.8 1977-2019 Several
f
Yes Yes
2 Burr, Richard (R, North Carolina) 1.6 2005-present Several
f
Yes No
3 McConnell, Mitch (R, Kentucky) 1.4 1985-present Yes
f
No Yes
4 Casey, Bob (D, Pennsylvania) 1.3 2007-present Several
f
Yes No
5 Clinton, Hillary (D, New York) 1.2 2001-2009 Several
f
No No
6 Murray, Patty (D, Washington) 1.1 1993-present Several
f
Yes No
7 Baucus, Max (D, Montana) 1.1 1978-2014 Yes
f
Yes No
8 Schumer, Charles (D, New York) 1.0 1999-present Yes
f
No Yes
9 Portman, Rob (R, Ohio) 1.0 2011-present Several
f
No No
10 Specter, Arlen (R, Pennsylvania) 1.0 1981-2011 Several
f
Yes No
11 Grassley, Chuck (R, Iowa) 0.9 1981-present Several
f
Yes Yes
12 Menendez, Robert (D, New Jersey) 0.9 2006-present Several
f
No No
13 Cornyn, John (R, Texas) 0.9 2002-present Several
f
No Yes
14 Santorum, Rick (R, Pennsylvania) 0.8 1995-2007 Several
f
No No
15 Wyden, Ron (D, Oregon) 0.8 1996-present Several
f
Yes No
16 Harkin, Tom (D, Iowa) 0.8 1985-2015 Several
f
Yes No
17 Alexander, Lamar (R, Tennessee) 0.8 2003-present Several
f
Yes No
18 Toomey, Pat (R, Pennsylvania) 0.8 2011-present Several
f
Yes No
19 Isakson, Johnny (R, Georgia) 0.7 2005-present Several
f
Yes No
20 Reid, Harry (D, Nevada) 0.7 1987-2017 Several
f
No Yes
Total 21.4 NA 20 12 6
Abbreviations: D, Democrat; NA, not applicable; R, Republican.
a
The table reflects congressional positions held at any point during the study
period (January 1, 1999, through December 31,2018). Some committees and
subcommittees changed names over the study period. Data on committee
memberships and Congressional positions were obtained from the US
Government Publishing Office.
27
b
Data obtained from the Center for Responsive Politics.
23
Monetary amounts
were inflation adjusted to 2018 dollars using the US Consumer Price Index.
c
See the Federal-Level Data section in the Methods section for a listing of
committees.
d
The member was the chair,vice chair, or ranking member of at least 1
health-related committee or health-related subcommittee. See the
Federal-Level Data section in the Methods section for a listing of committees
and subcommittees.
e
The member held at least 1 party leadership position in Congress (Speaker of
the House, majority leader, minority leader, majority whip, or minority whip in
the House; president pro tempore, majority leader, minority leader, majority
whip, or minority whip in the Senate).
f
The member served on at least 1 of the selected committees and at least 1
health-related subcommittee.
g
Anna Eshoo is currently chair of the Health Subcommittee in the House Energy
and Commerce Committee (2019-present).
Lobbying Expenditures and Campaign Contributions by the Drug Industry in the United States Original Investigation Research
jamainternalmedicine.com (Reprinted) JAMA Internal Medicine Published online March 3, 2020 E7
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the interests of all parties in society, not just those who seek
to improve their access to officials through campaign contri-
butions and lobbying expenditures. In the health sector, sev-
eral organizations, notably PhRMA, the American Medical As-
sociation, the American Hospital Association, and the Blue
Cross Blue Shield Association, accounted for a disproportion-
ate share of spending on lobbying over the study period.
PhRMA and the American Medical Association have histori-
cally lobbied together against government interventionsin drug
markets.
35-38
For example,although both groups supported the
Affordable Care Act, they did so only after receiving commit-
ments from the Obama administration and former Senator Max
Baucus (D, Montana), then chair of the Senate Finance Com-
mittee, that parallel import of lower-cost medicines from
Canada would not be permitted, Medicare would not be al-
lowed to negotiate drug prices, and Medicare payments tophy-
sicians would not be reduced.
35
With the exception of a few
influential consumer groups that have lobbied Congress to
lower drug prices—such as AARP—groups representing con-
sumers spent far less on lobbying than industry trade groups
and companies.
The $4.7 billion spent by the pharmaceutical and health
product industry on lobbying and the $1.3 billion spent on cam-
paign contributions from 1999 to 2018 was only about 0.1% of
the estimated $5.5 trillion (in 2018 dollars) spent on prescrip-
tion drugs in the US over the same period.
39
As a percentage
of their revenues, well-resourced drug industry groups had to
spend relatively little in their efforts to influencepolitic al and
legislative outcomes. In contrast, many organizations advo-
cating for the interests of patients and consumers have more
limited financial resources.
Legislative and regulatory changes might address some of
the disparities highlighted by this analysis. Such changes might
include restrictions on donations by individuals and organi-
zations to ballot measure committees at the statelevel. At pres-
sent, in many states, including California
40
and Ohio,
41
these
committees are not subject to contribution limits. Transpar-
ency about financial associations might also be increased, par-
ticularly for congressional leaders and members of commit-
tees that draft legislation affecting the pharmaceutical and
health product industry and other aspects of health care. For
example, Congress could mandate that chairs and ranking
members of health-related committees publish online, in a
readily accessible manner and in a format understandable to
the electorate, records of scheduled meetings with lobbyists
from relevant industries, as is required by the European
Parliament.
42
Limitations
This analysis had limitations. First, it was not possible to verify
the completeness of the data. However, the nonpartisan or-
ganizations from which the data were obtained conduct ex-
Figure 3. State-Level Contributions by the Pharmaceutical and Health Product Industry to Candidates, Party Committees,
and Ballot Measure Committees in Top 4 States, 1999-2018
250
200
150
100
50
0
Annual spending, $ in millions
Year
20171999 2001 2003 2005 2007 2009 2011 2013 2015
California
Prescription Drug Purchase
Standards Initiative
(Proposition 61)
Prescription Drug Discounts
and Rebates Initiatives
(Propositions 78 and 79)
40
30
20
35
25
15
10
5
0
Annual spending, $ in millions
Year
20171999 2001 2003 2005 2007 2009 2011 2013 2015
Missouri
Stem Cell Research and Cures
Initiative (Constitutional
Amendment 2)
70
50
60
40
30
20
10
0
Annual spending, $ in millions
Year
20171999 2001 2003 2005 2007 2009 2011 2013 2015
Ohio
Ohio Drug Price Relief
Act (Ballot Issue 2)
3.5
2.5
3.0
2.0
1.5
1.0
0.5
0
Annual spending, $ in millions
Year
20171999 2001 2003 2005 2007 2009 2011 2013 2015
New York
State Senate and Assembly
elections held every 2 years
Dashed lines show years with key ballot measures that affected the industry.
From 1999 to 2018,the pharmaceutical and health produc t industry
contributed $399 million in California, $74 million in Ohio, $43 million in
Missouri, and $33 million in New York. Contributions from 1999to 2002 may be
underestimated because of incomplete data. Data from the National Institute
on Money in Politics.
24
Amounts were inflation adjusted to 2018 dollars using
the US Consumer Price Index.
Research Original Investigation Lobbying Expenditures and Campaign Contributions by the Drug Industry in the United States
E8 JAMA Internal Medicine Published online March 3, 2020 (Reprinted) jamainternalmedicine.com
Downloaded From: https://jamanetwork.com/ by a London School of Economics User on 03/04/2020
tensive validation and triangulation of sources to ensure
accuracy.
23,24
Even so, the data did not capture all lobbying ac-
tivities because some expenditures fell outside of the disclo-
sure requirements (eg, small outlays and certain indirect ex-
penses, such as investments in buildings and infrastructure).
Second, there were inconsistencies among companies in the
reporting of lobbying expenditures, which made it difficult to
ensure the comparability of figures. Organizations in the phar-
maceutical and health product industry report federal lobby-
ing incomes or expenditures to the Senate Office of Public Rec-
ords through 1 of 3 filing methods.
23
The first 2 methods adhere
to the definition of lobbying in the Internal Revenue Code (1
method for for-profit groups and 1 for nonprofit groups),
43,44
whereas the third method follows the definition in the Lobby-
ing Disclosure Act of 1995.
45
The 2 filing methods based on the
Internal Revenue Code definition require filers todisclose state
and grassroots lobbying costs alongside federal lobbying costs,
whereas the other method does not. Moreover, the Lobbying Dis-
closure Act of 1995 definition covers a larger number of public
officials than the definition in the Internal Revenue Code.
Third, in any given year, the Center for ResponsivePolitics
23
and the National Institute on Money in Politics
24
were unable
to categorize approximately 30% and 15%, respectively,of dol-
lars spent on campaign contributions from individuals by in-
dustry because of lack of information. Thus, contributions at
both state and federal levels may have been underestimated
for the pharmaceutical and health product industry.
24,46
The
2 organizations categorize contributions from individual do-
nors based on self-reported employment information.
Fourth, ata state level, data on lobbying expenditures were
excluded from this analysis owing to unavailability, and data
on campaign contributions from 1999 to 2002 were likely un-
derestimated because of incomplete reporting. Also, state-
level data on campaign contributions excluded independent
spending (ie, money spent on communications with the pub-
lic by individuals or organizations that operated indepen-
dently of and not in coordination with candidates’ commit-
tees). This included spending on direct advocacy
communications (ie, “a communication, such as a website,
newspaper, TV or direct mail advertisement thatexpressly ad-
vocates the election or defeat of a clearly identified
candidate”
47
), electioneering communications (ie, “any broad-
cast, cable or satellite communication that refers to a clearly
identified…candidate, is publicly distributed within 30 days
of a primary or 60 days of a general election and is targeted to
the relevant electorate”
48
), and internal communications tar-
geted to members of a union or organization. Legal defini-
tions of each type of communication vary among states.
Fifth, the federal-level data only reflected campaign con-
tributions to outside spending groups registered with the Fed-
eral Election Commission; this excluded contributions to out-
side spending groups that report to the Internal Revenue
Service (eg, so-called 527 organizations, which can engage in
electioneering communications). The federal-level data on
campaign contributions also excluded direct advocacy com-
munications paid for by corporations out of their own trea-
suries, which became legal following the ruling in the 2010 Su-
preme Court case of Citizens United v Federal Election
Commission
26
; direct advocacy communications are referred
to as independent expenditures in federal campaign finance
regulations.
Conclusions
From 1999 to 2018, the pharmaceutical and health product in-
dustry spent large sums of money on lobbying and campaign
contributions to influence legislative and election outcomes.
Understanding the spending of the pharmaceutical and health
product industry on lobbying and campaign contributions can
inform discussions about how to temper the influence of in-
dustry on US health policy.
ARTICLE INFORMATION
Accepted for Publication: January 29, 2020.
Published Online: March 3, 2020.
doi:10.1001/jamainternmed.2020.0146
Open Access: This is an open access article
distributed under the terms of the CC-BY License.
© 2020 Wouters OJ. JAMA Internal Medicine.
Author Contributions: Dr Wouters had full access
to all the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Wouters.
Acquisition, analysis, or interpretation of data:
Wouters.
Drafting of the manuscript: Wouters.
Critical revision of the manuscript for important
intellectual content: Wouters.
Statistical analysis: Wouters.
Administrative, technical, or material support:
Wouters.
Study supervision: Wouters.
Conflict of Interest Disclosures: None reported.
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... El sistema de salud estadounidense, es muy peculiar como expresión de un capitalismo sin bridas (Suarez-Villa, 2016), dominado por las industrias de seguros, salud, y farmacéuticas, ya sea a través del control oligopólico de precios, el cabildeo en el Congreso de ese país, o el apoyo a la reelección de políticos (Wouters, 2020). No obstante, el ejemplo de arriba es pertinente para ilustrar las dificultades y el tiempo que toma, implantar reformas a la atención de salud pública, aun siguiendo las mismas normas impuestas en países desarrollados. ...
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La pregunta obligada, entonces, fue ¿cuán preparados estamos en Venezuela para afrontar los retos tecnológicos del sector salud?; y, ¿qué tipo de organizaciones sociales a escala nacional, podrán orientar la necesaria adaptación a tales cambios estructurales? La respuesta es importante y no tanto como precondición para ser partícipes o autores de tales mutaciones en beneficio de nuestra comunidad, sino como paso inicial para siquiera entender la naturaleza, ventajas, limitaciones y riesgos, de este tipo de atención sanitaria emergente. El reto, sin duda alguna, atiene a las corporaciones referentes de la medicina y la ciencia venezolana, es decir, a las academias, las sociedades médicas o científicas, y las universidades nacionales de investigación. Los resultados de la investigación, tal como aparecen en el Capítulo I de este trabajo, son positivos en cuanto al grado de preparación de nuestras universidades. El Capítulo 2, describe nuestra propia experiencia en medicina digital; y el Capítulo III, examina en el país, el estado del arte en las investigaciones clínicas y la medicina basada en evidencias, así como proyecta las posibles soluciones de una transición gradual hacia un modelo de medicina digital. El Capítulo IV, analiza la productividad y el impacto científico de la Academia Nacional de Medicina como corporación doctrinaria de. la medicina venezolana. El Capítulo V, describe el funcionamiento e impacto del Portal Digital de la referida Academia, en particular para explicar el uso de las nuevas tendencias biomédicas para resolver en parte, la pandemia COVID-19 durante 2020-2021. El Capítulo VI, atiende las principales propiedades de la medicina digital, así como las condiciones necesarias para su implantación futura en Venezuela. El Capítulo VII, describe cómo podría ser la transición de la medicina actual hacia un sistema digital de atención universal y personalizada a la salud en Venezuela. En particular, este capítulo encara las reformas estructurales y legislativas que serán necesarias para hacer una realidad de esta posible transición: a la vez que plantea una visión gerencial sobre cómo llevarlas a cabo a la luz de la experiencia de los autores, y de reformas similares llevadas con mucho éxito en los países más avanzados del planeta. A modo de colofón, el Capítulo VIII, presenta un diálogo virtual historiográfico, sin barreras de tiempo y espacio entre 1892 y 2021, con la “participación” de grandes líderes del desarrollo médico y científico, que responden a tres preguntas sobre el impacto en la formación del médico, de la investigación, la formación profesional integral, y el rol en esas lides de una academia nacional de medicina. Palabras clave: educación médica, ciencias biológicas, investigación biomédica, universidad, academias, medicina basada en evidencia, historia, cienciométrica, bibliométrica, medicina digital. SUMMARY The purpose of this work is to present a vision that may guide the future transformation of Venezuelan medicine, into a digital system of universal health care, through the adoption of frontier biomedical technologies. For this, and as a primary objective, we conducted research on the level of preparation of our scientific community to assimilate for their own benefit, the biomedical trends that shape medicine in advanced countries. With this objective, we examine the state of biomedical research and teaching in the country, both in academia and in various scientific societies and research universities. The methodology used combines scientometrics, historiographies, scientific connectivity or graph analysis, artificial intelligence, webinars, and virtual forums, with configurational logic. In a previous post with similar methods, it was possible to demonstrate how one hundred years of research in Venezuela on Chagas disease and Trypanosoma cruzi, were key to the development of various specialties of national medicine, as well as to accelerate the country's progress in multiple disciplines of biological sciences. The spirit of this research, therefore, starts from the hypothesis that when examining under the most demanding criteria of universal scientific validity, the roots and current state of our development in national corporations of excellence, such as the National Academy of Medicine and the national universities that carry out research, it will be possible to glimpse a path towards new directions that will allow the country to catch up with the pace of future actions imposed by the new technologies that shape the 21st century, both in medicine and in biomedical sciences. The obligatory question, then, was how prepared are we in Venezuela to face the technological challenges of the health sector? And what kind of social organizations at the national level will be able to guide the necessary adaptation to such structural changes? The answer is important and not so much as a precondition to the participants or authors of such mutations for the benefit of our community, but as an initial step to even understand the nature, advantages, limitations, and risks of this type of emerging health care. The results of the investigation, as they appear in Chapter I of this work, are positive in terms of the degree of preparation of our universities. Chapter II goes further on to describe our own experience on digital medicine in Venezuela. Chapter III examines the state of the art in clinical research and evidence-based medicine in the country, as well as to project possible solutions for a gradual transition towards a digital model system of medicine. Chapter IV analyzes the productivity and scientific impact of the National Academy of Medicine as a doctrinal corporation of Venezuelan medicine. Chapter V describes the operation and impact of the Digital Portal of the Academy, in particular those items that contribute to explain the use of new biomedical trends to partially resolve the COVID-19 pandemic during 2020-2021. Chapter VI deals with the main properties of digital medicine, as well as the necessary conditions for its future implementation in Venezuela. Chapter VII describes how the transition from current medicine to a digital system of universal and personalized health care, could be implemented in Venezuela. This chapter deals with the structural and legislative reforms that will be necessary to make this transition a reality, and at the same time, it proposes a managerial vision on how to carry them out in the light of the authors' experience. As a climax, Chapter VIII presents a virtual historiographical dialogue, without barriers of time and space between 1892 and 2021, with the "participation" of great leaders of medical and scientific development, who answer three questions about the impact on the medical training, research, comprehensive professional training, and the role of a national academy of medicine in these matters. Keywords: medical education, biological sciences, biomedical research, university, academies, evidence-based medicine, history, scientometrics, bibliometrics, digital medicine.
... Resonating with our findings, an analysis in the USA found that the pharmaceutical and health product industry spent US$4.7 billion between 1999 and 2018 on lobbying the federal government, with contributions targeting senior legislators in Congress involved in drafting healthcare laws as well as committees involved in drug pricing and regulation. 28 Financial ties between pharmaceutical companies and 'independent' policy advisors or government officials is also widespread. For example, in the UK, where the health system is not dominated by private healthcare provision, members of the Vaccine Taskforce were found to have financial interests in pharmaceutical companies from which the government purchased COVID-19 diagnostic tests and treatment. ...
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... El sistema de salud estadounidense, es muy peculiar como expresión de un capitalismo sin bridas (Suarez-Villa, 2016), dominado por las industrias de seguros, salud, y farmacéuticas, ya sea a través del control oligopólico de precios, el cabildeo en el Congreso de ese país, o el apoyo a la reelección de políticos (Wouters, 2020). No obstante, el ejemplo de arriba es pertinente para ilustrar las dificultades y el tiempo que toma, implantar reformas a la atención de salud pública, aún siguiendo las mismas normas impuestas en países desarrollados. ...
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... To illustrate this matter, an observational study (Wouters, 2020) found that between 1999 and 2018, the pharmaceutical and health products industry spent $4.7 billion lobbying the U.S. federal government, contributions to presidential candidates, and legislative and party committees. The same is true in the European Union and in other countries, and in other industrial sectors. ...
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... The strength of these organizations is determined by how much the government requires them and their ability to establish personal contacts with policymakers. Given their extensive resources, government connections and the government's reliance on them for foreign investment and economic benefits, multinational pharmaceutical companies and business associations wield considerable power (Wouters, 2020). ...
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