Mr. Counts contributed to the conceptualization and design, acquisition of data, and drafting of the manuscript. Dr. Taylor, Dr. Willison, and Dr. Galea contributed to the analysis and interpretation of data as well as critical revision of the manuscript for important intellectual content.
* Corresponding Author: Nathaniel Z Counts, JD, Senior Vice President, Behavioral Health Innovation, Mental Health America, 500 Montgomery St, Suite 820, Alexandria, VA 22314, gro.lanoitanahm@stnuocn
The publisher's final edited version of this article is available at Prev MedHealthcare stakeholders are increasingly investing to address social determinants of health (SDOH) as they seek to improve health outcomes and reduce total healthcare costs in their communities. Policy heavily shapes SDOH, and healthcare lobbying on SDOH issues may offer large impacts through positive policy change. Federal lobbying disclosures from the ten highest spending health insurance and healthcare provider organizations and related associations between 2015 and 2019 were reviewed to identify lobbying reported on the salient SDOH issues, defined based on the Accountable Health Communities Model health-related social needs screening tool. Five of the organizations reported lobbying on some SDOH issues, including financial strain, employment, food insecurity, and interpersonal safety, but none reported lobbying on other issues, such as non-healthcare-related employment, housing instability, transportation, or education. Lobbying has been a missed opportunity for addressing SDOH. Healthcare organizations have the opportunity to expand their lobbying on upstream SDOH policy issues to increase the impact of their SDOH strategy and further improve population health.
Keywords: social determinants of health, health policy, healthcare reformThere is little doubt that social and economic factors can contribute more to some health outcomes than clinical interventions. 1,2 A growing body of evidence demonstrates ways in which social and economic factors can be modified by intervention, and how this in turn improves health. 3 As a result of these findings, healthcare stakeholders are increasingly focusing on addressing social determinants of health (SDOH) to improve population health and reduce healthcare costs. 4,5 Leading health insurers and healthcare providers have directly invested in addressing SDOH-related issues, employing strategies that range from creating referral networks for social services to building new community assets, such as affordable housing or food pantries. 6
Direct investments are one critical part of an effective strategy to address SDOH, but lobbying for policy change related to SDOH may offer greater impact. The SDOH acknowledged in healthcare are the result of larger social and economic structures that (unevenly) distribute health risks and opportunities across a society, and are primarily constituted by policy decisions – thus making them “socially determined.” 7 Direct investments can help correct for poor policy choices for a given community, but lobbying for policy change can reorient social and economic structures to promote more systemic, equitable, and sustainable improvements in SDOH. 8,9,10
Corporate law and theory examine the regimes that govern corporations and how these regimes impact the larger society. One area of focus is corporate purpose – what is the goal of a corporation and how should management make decisions? Scholarship indicates that corporations, as separate entities from the individuals that make them up, choose to invest in lobbying or other domains based on the decisions of those that govern them (i.e. the management team and board) to advance the corporate purpose. 11 In general, for for-profit corporations, the corporate purpose is the interests of the shareholders (often, but not always, profit maximization); for non-profits, it is the stated charitable cause (and profits necessary to achieve impact on that cause); and for associations, it is the interests of the members. Thus, corporations or associations representing them may choose to lobby because it produces direct financial returns in the form of a more favorable policy environment, because it produces reputational benefits that in turn offer financial returns from greater favorability among customers and employees, or in some cases because it is related to their charitable causes or values of the shareholders or members. 12 These types of considerations likely motivate healthcare corporations and associations to directly invest in SDOH, and these considerations could also motivate them to lobby on SDOH issues.
If investing directly in SDOH offers financial returns or aligns with core values, then investing in lobbying on SDOH policy change may offer greater returns and potentially cost substantially less. 13 For example, lobbying on affordable housing policy may cost less and produce greater impact than directly financing the development of new affordable housing. The same is likely true across a range of critical SDOH policy areas, from tax and safety net policy to education and employment. Healthcare is the top sectors for total federal lobbying spending, at over $600 million in 2019, and healthcare organizations make up many of the highest lobbying spenders each year in the US. 14 Healthcare organizations likely also wield substantial political influence at the state and local levels as well. If leading healthcare organizations lobbied on SDOH issues, they could potentially have a substantial policy impact given their large presence – increasing the likelihood of realizing direct financial, indirect reputational, or values-oriented benefits from the investment.
Little is known, however, about the extent to which healthcare organizations lobby on SDOH issues. This article reviews federal lobbying disclosures from healthcare organizations with the highest lobbying spending between 2015 and 2019 to analyze lobbying on SDOH.
The search queried the Open Secrets database from the Center for Responsive Politics, which extracts text from all federal lobbying disclosures required by the Lobbying Disclosure Act of 1995 and its amendments and presents them in a searchable format. 15 The Open Secrets database ranks spending by industry, and these rankings were used to identify the top five spenders from 2015 to 2019 among health insurers (from the Insurance and Health Services/HMOs industry classifications) and top five among physicians and hospitals (from the Health Professionals and Hospitals/Nursing Homes industry classifications), excluding organizations that focus only on subpopulations, such as dialysis services.
The years 2015 to 2019 were selected because discourse around SDOH increased around this timeframe and this range of years offers enough time for lobbying opportunities across various SDOH policy issues to become relevant. 16 Some SDOH issues may not be a political priority in a given year (e.g. a Congressional committee prioritizes banking policy over housing policy for a year), in which case organizations may choose not to prioritize that issue when they have several to choose from, but over five years most issues will have become a political priority for at least some period of time.
For choosing which healthcare organizations to analyze, lobbying in healthcare is highly skewed, with one study finding that thirty healthcare organizations made up 40.1% of all lobbying in healthcare between 2018 and the first quarter of 2020 (18 of which were pharmaceutical or dialysis organizations). 17 To capture those organizations that likely exert the greatest influence on policy-making in the sector and that benefit from broadly addressing SDOH, we selected the top five insurer and top five provider organizations and related associations, removing pharmaceutical or more niche healthcare organizations. Although other organizations exert important political influence, lobbying from these ten organizations can be illustrative.
In each lobbying disclosure, organizations are required to list the specific issues they lobbied on and classify these issues under as many predetermined categories as relevant (such as Tax, Housing, or Health). Relevant SDOH issues were determined based on the domains used in the US Center for Medicare & Medicaid Innovation’s Accountable Health Communities Model (AHCM) health-related social needs screening tool, and ultimately included: housing instability, food insecurity, transportation problems, physical activity (i.e. neighborhood safety and built environment that facilitates physical activity), financial strain or utility help needs, employment, education, employment, family and community support (i.e. neighborhood conditions that contribute to building social capital), and interpersonal safety. 18 The AHCM screening tool was used over other SDOH taxonomies because it represented a political decision in the US about what specific domains of SDOH healthcare stakeholders can and should prioritize, and because limiting to specific domains guides the interpretation of lobbying disclosures, which are open-text and often difficult to interpret. For this analysis, SDOH lobbying was defined as lobbying on these SDOH domains that would make additional resources available, such as additional funding for food assistance programs, or that would advance regulations to better protect health, such as policies that make healthy food options more accessible. Lobbying on healthcare-specific aspects of SDOH issues, such as coordination between healthcare and social services or workforce development in health professions, was excluded along with any lobbying on SDOH issues classified solely under the “Health” category. This definition thus captures lobbying on the upstream SDOH policy issues, rather than downstream healthcare system-based interventions to address them.
For each of the ten organizations, the total lobbying spending in each year and lobbying disclosure in each quarter between 2015 and 2019 was extracted, including spending and disclosures from contracted lobbyists and subsidiaries. Disclosures appear as open text notes on what issues were lobbied on, with high variability in the level of specificity offered. The lobbying disclosures were reviewed by issue for any reported lobbying that matched the SDOH lobbying definition set forth above. The potential SDOH lobbying identified was then reviewed by all authors and consensus was reached on final inclusion.
The ten organizations included in the study included two national associations of health insurers, three large health insurance companies, three national associations of hospital systems, and two national associations of physicians. Two of the national associations of insurers and two of the national associations of hospitals contained both for-profit and non-profit members, while one association of hospitals was solely comprised of for-profit members. The three large health insurance companies were all for-profit. One of the national associations of physicians represented all types of physicians while the other represented a primary care specialty.
They spent a combined $507,497,955 on federal lobbying between 2015 and 2019, spending an increasing amount year-to-year. Spending by these 10 organizations made up almost 20% of all federal healthcare lobbying nationally during this time. Of these companies, two insurer and three provider organizations reported lobbying on the SDOH issues, including: financial strain (reduced tax on feminine hygiene products), employment (workplace diversity, hiring underserved populations, and pregnancy discrimination and leave policies), nutrition and food policy, and interpersonal safety ( Table 1 ). No lobbying was reported on many of the SDOH issues, such as non-health-related housing, transportation, or education. The two associations representing physicians lobbied on the most SDOH topics, the association that includes non-profit hospitals lobbied only on food and nutrition, and the two for-profit health insurance companies lobbied only on employment policy.
Top Healthcare Lobbying Organizations and Reported Lobbying on SDOH, 2015–2019
| Organization (inc. subsidiaries) | Mean Annual Lobbying Spend | Social Determinants of Health Issues Lobbied On |
|---|---|---|
| Blue Cross Blue Shield Association | $24,683,855 | None identified |
| American Hospital Association | $23,228,856 | Nutrition and food policy |
| American Medical Association | $20,842,400 | Financial strain (feminine hygiene products tax), interpersonal safety |
| America’s Health Insurance Plans | $7,872,000 | None identified |
| Cigna | $6,166,000 | None identified |
| Aetna (CVS Health as of 2019) | $4,625,400 | Employment (hiring underserved populations) |
| Children’s Hospital Association | $3,914,000 | None identified |
| UnitedHealth Group | $3,830,000 | Employment (workplace diversity) |
| American Academy of Family Physicians | $3,311,080 | Nutrition and food policy, interpersonal safety, employment (leave policies and pregnancy discrimination) |
| Federation of American Hospitals | $3,078,000 | None identified |
Although not formally included in this analysis, several organizations reported lobbying on other SDOH issues that fell outside of the AHCM screening tool domains, such as immigration or environmental health. Many also lobbied on healthcare-related aspects of SDOH, such as caregiver tax credits or social needs data collection and coordination.
The ten organizations that spent the most on federal lobbying in the US each invested millions of dollars annually in lobbying. No lobbying on SDOH issues was identified for five of the organizations, lobbying on one SDOH issue was identified for three organizations, and lobbying on multiple SDOH issues was identified for two organizations. Interestingly, none of the organizations reported lobbying on housing policy, despite the mounting discourse on the importance of access to stable housing for health. 19
Corporate law and theory may explain some of the lobbying observed. The associations of physicians may have chosen to lobby on SDOH issues because of its alignment with member values. To the extent that the physicians are in value-based payment models or financially liable for uncompensated care, they could benefit financially as well, although this is probably only a smaller proportion of the members. The association that includes non-profit hospitals would be more likely to benefit financially from addressing social needs in some contexts or receive advantages from reputational benefits (e.g. being viewed more favorably in other lobbying activities), although members values could have driven its decision to lobby on a SDOH policy issue. The two for-profit insurance companies may have directly financially benefited from the employment policy issues, engaged as part of growing commitments to environmental, social, and governance (ESG) responsibilities around diversity, equity, and inclusion, or to reflect shareholder values. 20 From this small sample and with the difficulty of analyzing SDOH lobbying, it is difficult to infer how for-profit as opposed to non-profit corporate forms or memberships impact SDOH lobbying, although it is notable that the associations of individual healthcare providers reported the most SDOH lobbying.
There are also several reasons that could explain why we did not identify more SDOH lobbying. Organizations may not expect sufficient direct financial returns from national-level policy change and may be focused more at the state or local level, or they may have already received maximum reputational benefit from other SDOH-related activities, and thus stay focused on healthcare-specific issues. Some SDOH policy proposals may also lead to less direct financial returns for healthcare organizations if, for example, an increase in social spending is offset by an increase in taxes on the organizations. In some cases, organizations may also fear that lobbying for multiple priorities simultaneously will decrease their likelihood of succeeding on the issues that bring them the largest direct financial returns, or that it may dilute their overall influence. If motivated by the values of the shareholders or members, organizations may prioritize issues within healthcare to address that add social benefit and that the organization feels greater competency in, rather than SDOH issues. Finally, the emerging focus on SDOH may in some cases be led by designated components within each organization that are siloed from other divisions, such that SDOH has not yet become a priority across divisons. 21 As the focus on SDOH diffuses across divisions, healthcare organizations may increasingly engage in SDOH lobbying.
Public and private stakeholders could take actions to better align corporate incentives for lobbying on SDOH issues. For example, other SDOH lobbying stakeholders could publicly recognize healthcare lobbying on SDOH issues to enhance the associated reputational benefits. Federal and state health policy could ensure that healthcare stakeholders internalize more of the benefits of reduced healthcare spending associated with addressing SDOH, making the direct financial returns of SDOH lobbying greater. For example, payment policies for public health insurance plans or accountable care organizations often prevent stakeholders from sharing in savings associated with prevention. 22 Stakeholders could also continue to increase awareness of both the public health and financial benefits of addressing SDOH so that it is more likely to be prioritized, building on initiatives such as the Center for Disease Control and Prevention’s Health Impact in 5 Years (HI-5) Initiative. 23 This includes highlighting how federal policy change, the effects of which may seem diffuse to stakeholders, produce local impacts.
If healthcare corporate incentives were better aligned to promote SDOH lobbying, these top lobbying healthcare organizations have an opportunity to expand their SDOH lobbying and potentially impact SDOH policy issues. The top healthcare lobbying organizations have influenced high-profile health-related federal policies over the years – such as the Affordable Care Act – as they represent substantial interests in the health sector and their spending allows them to effectively transmit their perspectives to policymakers. 18 Lobbying from these highest spending organizations would likely be similarly impactful when applied to SDOH, where they already have high visibility and could offer a health viewpoint on each issue. In particular, leading healthcare organizations could direct their contract lobbyists, who may have broader political connections and policy experience than more specialized in-house lobbyists, to advance SDOH issues. They could also bolster the efforts of existing advocacy coalitions already working in each SDOH policy area, such as affordable housing or healthy food access coalitions – mitigating the need to develop expertise while lending the political power of healthcare to these movements. If top healthcare organizations lobbied on SDOH issues, it is possible that they may be able to achieve policy impacts for relatively little additional investment.
While corporate lobbying may be at odds with effective social policy in some domains, 19 the potential for aligned interests in the healthcare sector for addressing SDOH present a critical opportunity for lobbying that advances effective social policy. Successful lobbying on SDOH could lead to policy changes that address upstream causes of poor health and fundamentally improve health outcomes and reduce costs across the nation. At least some SDOH policy changes align with or can be aligned with the corporate incentives of the largest healthcare organizations, and the healthcare organizations with the highest lobbying spending have the opportunity to further prioritize lobbying as a strategy for advancing health equity and reducing healthcare costs by addressing SDOH. In doing so, these organizations may be able to shape a more favorable policy environment for health across the US while realizing greater overall financial returns.
This analysis faced several limitations. The analysis only covered ten organizations over five years, and the organizations included are not likely representative of healthcare lobbying as a whole. Because some organizations used general language to describe their lobbying, SDOH lobbying may have occurred that could not be identified from the disclosures. In many cases, organizations lobbied on bills with a wide array of provisions (such as major tax legislation), some of which included SDOH issues. This lobbying was not included unless the specific provisions were identified as a lobbying issue in the disclosure, and thus some SDOH lobbying may have been missed. Because the review was limited to lobbying on issues related to domains from the AHCM screening tool, lobbying on other issues was not included. Further, activities that have political influence that are not captured in the disclosures, such as producing thought leadership pieces on SDOH, were not included in the study. Little could be discerned about the specific nature of the lobbying as well – it is also not possible to determine how much was spent on each lobbying activity and it is difficult to determine what lobbying activities occurred with the information available in the disclosures.
The review was also limited to those SDOH policy issues included in the AHCM screening tool, which reflects what federal regulators – with input from external stakeholders – found to be the most relevant social needs for health outcomes and healthcare costs that were actionable for healthcare systems at a community-level. It may be however, that the SDOH issues that stakeholders want to prioritize at a federal level differ from those they prioritize in their communities. For example, some amount of lobbying was identified on environmental health issues that was not included in the review.
Future research should study factors that contribute to organizational decisions on SDOH lobbying and the impacts that increased SDOH lobbying would have on health equity and healthcare costs. Research should also examine healthcare organizations’ state and local lobbying, which are also critical for impacting SDOH and may involve different considerations than federal lobbying.
Healthcare organizations’ mandatory lobbying disclosures provide a partial view of their political influence activities, and by analyzing these disclosures researchers can study the policy priorities and lobbying of healthcare organizations. By studying lobbying disclosures, we found that the healthcare organizations that spend the most on lobbying reported lobbying on some, but not many, important SDOH issues between 2015–2019. The healthcare organizations that spend the most on lobbying have the opportunity to increase their lobbying on SDOH issues, strengthening their SDOH strategy and potentially impacting key policies that influence health in the US.
The healthcare organizations that spend the most on lobbying could impact policies related to social determinants of health.
The top lobbying healthcare organizations in the US do not lobby on many key social determinants of health issues.
Leading healthcare organizations should consider lobbying as part of their social determinants of health strategy.
Dr. Willison received support from the National Institute of Mental Health of the National Institutes of Health under Award Number T32MH019733. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Ethical approval was not required for this study because there were no human participants in the research design.
| SDOH | Social determinants of health |
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The authors have no conflicts of interest to report.
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