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A correction has been published: N Engl J Med 1995;332(21):1450.
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Background The American Medical Political Action Committee (AMPAC), the political arm of the American Medical Association (AMA), contributed $2.4 million to candidates for Congress during the 1989-1990 campaign and $2.9 million during the 1991-1992 campaign. It is not known whether these funds preferentially benefited representatives who supported the AMA's positions on public health issues.
Methods We analyzed AMPAC contributions to members of the House of Representatives during the 1989-1990 and 1991-1992 campaigns according to their votes on three health-related issues: the promotion of tobacco exports, the institution of a mandatory waiting period before a handgun purchase, and the so-called gag rule, which limited physicians' speech on abortion in federally funded clinics. For each issue, we determined whether AMPAC had contributed more on average to opponents or to supporters of the official AMA position.
Results AMPAC contributed more on average to opponents of the AMA positions on all three public health issues. From 1989 to 1992, AMPAC gave significantly larger average contributions to House members who favored tobacco-export promotion than to those who opposed it ($11,549 vs. $9,842, P = 0.04) and contributed significantly less on average to supporters of handgun control than to their opponents ($9,022 vs. $11,250, P = 0.001). During the same period, AMPAC's contributions revealed a marked preference for House members who supported the gag rule over those who opposed it ($10,961 vs. $9,611, P = 0.05). House members who supported the AMA positions on all three votes received an average of $8,800 from AMPAC from 1989 through 1992, whereas members who opposed all three positions received an average of $13,270 (correlation between the number of votes for AMA positions and AMPAC contributions, -0.21; P<0.001).
Conclusions AMPAC's contributions to members of the House of Representatives belie the AMA positions on some important public health issues.
With health care at the top of the nation's agenda, increasing numbers of physicians are contributing to the American Medical Political Action Committee (AMPAC), the political wing of the American Medical Association (AMA). The largest political action committee associated with health care in the country, AMPAC distributed $2.9 million to candidates for Congress during the 1991-1992 election season -- a 21 percent increase over the $2.4 million given out during the 1989-1990 campaign1.
It is not known whether the AMPAC funds preferentially benefited representatives who support the AMA position on health-related issues. Using records filed with the Federal Election Commission, we analyzed AMPAC contributions to members of the House of Representatives during the 1989-1990 and 1991-1992 campaigns according to how the members had voted on three health-related issues: the promotion of tobacco exports, the institution of a mandatory waiting period for handgun purchases, and the "gag rule" limiting physicians' speech on abortion in federally funded clinics. For each vote we determined whether, on average, AMPAC had contributed more to opponents or to supporters of the official AMA position.
Vote 1: Tobacco-Export Promotion
There may be no stronger consensus in American medicine today than that in opposition to the tobacco industry. In 1990 smoking killed 418,690 Americans,2 and it has been estimated that by about 2025 tobacco-caused disease will kill 10 million people each year, including 7 million in the developing world3. For these reasons, official AMA policy since 1986 has stated that "the AMA (1) opposes any efforts by the government or its agencies to actively encourage, persuade or compel any country to import tobacco products; and (2) favors legislation that would prevent the government from actively supporting, promoting or assisting such activities"4.
In Congress, however, the powerful tobacco industry has been able to obtain federal resources to open tobacco markets in other countries. In fiscal year 1992, the United States spent $3.5 million to promote sales of U.S. tobacco abroad. For fiscal year 1993, Representative Wayne Owens (D-Utah) offered an amendment to the agriculture appropriations bill to prohibit the use of funds for this purpose. The amendment passed by a vote of 331 to 82 on June 30, 19925.
Vote 2: Handgun Control
Violence is recognized as a growing public health issue in America. An editorial in the Journal of the American Medical Association noted that "one million U.S. inhabitants die prematurely each year as the result of intentional homicide or suicide" and that "the leading cause of death in both black and white teenage boys in America is gunshot wounds." It went on to urge physicians to "demand legislation intended to reverse the upward trend of firearm injuries and deaths, the end result that is most out of control"6.
Such legislation was considered in the House of Representatives in May 1991. The Brady bill, named after the press secretary injured during an attempt to assassinate President Ronald Reagan, would have required a seven-day waiting period before the purchase of a gun to allow time for a comprehensive background check of the prospective purchaser. The AMA lobbied for the bill, writing to all House members to urge their unconditional support. The letter concluded: "Physicians are first-hand witnesses to the horrendous cost in human life being exacted by firearm violence. Because of that experience, we urge you to support [the Brady bill] and to accept no substitute for this vitally important public safety measure"7.
The Brady bill passed the House by a vote of 239 to 186 -- too small a margin to override a veto by President George Bush8. After this defeat, the legislation never passed the Senate during the Bush presidency. At the time its failure was a major victory for the National Rifle Association and went against the wishes of the American people, 89 percent of whom support a waiting period9. The Brady bill was finally passed and signed into law by President Bill Clinton in November 1993.
Vote 3: The "Gag Rule"
The privacy of the physician-patient relationship is cherished by every physician. It was also under attack by the Bush administration. President Bush's gag-rule regulation prohibited doctors in federally funded clinics from speaking about abortion with their patients. The rule, and the supporting Supreme Court opinion in Rust v. Sullivan, opened the doors to increased government control over physicians' speech10.
In November 1991 and again in August 1992, Congress tried to repeal the gag rule with support from the AMA. Raymond Scalettar, secretary-treasurer of the AMA, testified before Congress that the regulations "denigrate the integrity of the doctor-patient relationship and force health care professionals to violate established standards of medical care and professional ethics"11. The AMA's House of Delegates unanimously passed a resolution urging repeal of the gag rule.
Congress voted to repeal the regulation but fell just 12 votes short of overriding Bush's veto in November 199112. Soon after Bill Clinton's election in 1992, he issued an executive order repealing the gag rule.
Methods
AMPAC is the official political action committee of the AMA, listed with the Federal Election Commission. Although other medical associations and specialty groups are also affiliated with political action committees, we chose to focus on the AMA and did not analyze contributions from other groups. We chose to examine AMPAC contributions to House members rather than senators because there are fewer senators, only one third of whom face election in a given two-year period. We selected tobacco-export promotion, the Brady bill, and the gag rule as issues to analyze because of their generally acknowledged importance to the public health and because they were voted on in Congress between the 1990 and 1992 elections. In addition, the AMA took strong stands on these issues. We found no other issues with these characteristics in the course of reviewing the chapters on health legislation in the 1991 and 1992 editions of the Congressional Quarterly Almanac, a chronicle of congressional action. Finally, we believe the stance of the AMA reflects the consensus of medical opinion on these issues.
Eligibility for the Study
In analyzing AMPAC contributions during the 1989-1990 campaign, we included every House member who was elected in 1990, did not on principle refuse funds from political action committees during the campaign, and did not die or retire during the term. Of 435 members, 415 met these criteria. In examining contributions for the 1991-1992 campaign, we included all members who sought reelection in 1992, did not on principle refuse funds from political action committees during the campaign, and had not taken the seat of a House member who died or retired during the term. Three hundred thirty members met these criteria.
Of the members who met the eligibility criteria for the study, some were not present for the votes in question and thus could not be included in the analysis of those votes. Of the 415 members eligible for the analysis of the 1989-1990 campaign, 22 missed the vote on tobacco-export promotion, 6 missed the vote on the Brady bill, and 2 missed the vote on the gag rule. Of the 330 members eligible for the analysis of the 1991-1992 campaign, 13 missed the vote on tobacco-export promotion, 3 missed the vote on the Brady bill, and none missed the vote on the gag rule.
Sources of Data
We obtained information on AMPAC contributions to House members during the 1989-1990 and 1991-1992 election seasons from the public records office of the Federal Election Commission. We found the roll-call votes on the three health-related issues in Congressional Quarterly Weekly Report, a journal that details all congressional actions. Common Cause, a nonpartisan congressional watchdog group, provided us with a list of House members who refused donations from political action committees. From the Congressional Quarterly Weekly Report, we identified six districts whose representatives had died or retired between the 1990 and 1992 elections. Finally, we determined which members had not sought reelection in 1992 by noting which members did not appear, as either winners or losers, in the official results of the 1992 general election as compiled by the Federal Election Commission.
Analysis of Data
Using a statistical-analysis program (Stata version 3.0), we gathered relevant data on each of the 435 congressional districts, including the House member's name, the AMPAC contributions in each election season, the member's roll-call votes on the three health-related issues, whether the member accepted funds from political action committees, and whether the member ran for reelection in 1992. After entering the data, we checked them again against the original sources.
We then examined the data, restricting each analysis to the members eligible for that analysis. We began by studying AMPAC contributions during the 1989-1990 campaign and the gag rule. First, we determined the percentage of members supporting and opposing the gag rule who received AMPAC funds. For those who received funds, we computed the mean contribution made by AMPAC to the House members on each side of the issue and performed a t-test to evaluate the difference between the two means.
We repeated this analysis for the votes on the Brady bill and tobacco-export promotion and then examined all three issues again to analyze the contributions made during the 1991-1992 campaign and the total amount for the period 1989-1992. In analyzing contributions for both campaigns together, we excluded all House members who could not be included in either the 1989-1990 or the 1991-1992 election analyses. We used the nonparametric Wilcoxon rank-sum test to confirm all significant results of t-tests.
We then created a public health index that represented the number of votes each member had cast in agreement with the AMA positions. Only members who had voted on all three issues were included in the group for whom this index was calculated. A score of 3 on the public health index indicated that the member had supported the AMA positions on tobacco-export promotion, gun control, and the gag rule. In contrast, a score of 0 meant that the member had voted against the AMA positions on all three issues. We divided the members into four groups according to their scores on the public health index. For each group, we calculated the percentage of representatives who had received AMPAC contributions in each election and, for those who had received funds, the mean amount. We also tested the Pearson's and Spearman's coefficients for the correlation between the public health index and the size of AMPAC contributions. We report the Pearson's coefficient, but the nonparametric Spearman's coefficients were significant at P<0.05 as well. Analyses of the contributions for the 1989-1990 campaign, the 1991-1992 campaign, and both campaigns together all showed the same significant trend (P<0.05); to avoid redundancy, results are reported here only for both campaigns together. All P values are for two-tailed tests.
After reviewing the results and considering various hypotheses to explain them, we went back and included the ratings awarded to each House member by the American Conservative Union on the basis of that member's votes in 1991; this vote rating is widely used to judge where members stand in the political spectrum. We grouped the members according to their public health index and calculated the mean American Conservative Union rating for each group. We did this for members eligible for the 1989-1990 analysis, the 1991-1992 analysis, and the 1989-1992 analysis. We also calculated the Pearson's and Spearman's coefficients for the correlation between the vote rating and the public health index and for the correlation between the vote rating and AMPAC contributions. All the correlations for each period analyzed were significant (P<0.05), and Pearson's values are reported for the 1989-1992 AMPAC contributions. These findings are explained in the Discussion section, because the idea for this approach came as we sought explanations for the main results.
Results
Tobacco-Export Promotion
Despite the AMA's official stand against all "efforts by the government to encourage, persuade or compel any country to import tobacco products," AMPAC preferentially supported the proponents of such efforts in both the 1989-1990 and the 1991-1992 campaigns (Table 1).
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In the 1991-1992 campaign, 98.5 percent of House members favoring tobacco-export promotion received AMPAC funds, as compared with 90.8 percent of those opposed. AMPAC gave an average of $409 more to supporters of exports (P = 0.38).
Combining contributions for the four-year period revealed that every House member favoring tobacco-export promotion who ran in the 1990 and 1992 elections received AMPAC funds, as compared with 96.0 percent of those opposing the measure. AMPAC contributed an average of $11,549 to supporters of tobacco exports, whereas House members who took the stand of the AMA received an average of $9,842 (P = 0.04).
Handgun Control
AMPAC also supported opponents of the AMA position on handgun control (Table 2). In the 1989-1990 campaign, 84.6 percent of representatives who later backed the Brady bill received AMPAC contributions, but so did 91.2 percent of those who voted against it. Among those who were sent AMPAC contributions, those who later supported the Brady bill received an average of $4,522, but their opponents received an average of $5,607 (P = 0.002).
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When all contributions from 1989 through 1992 are considered, AMPAC significantly favored representatives who voted against what the AMA itself considered "a vitally important public safety measure." Among those who competed in the 1990 and 1992 elections, 99.3 percent of opponents of the Brady bill received funds, as compared with 94.9 percent of supporters. AMPAC gave the opponents an average of $11,250, whereas the advocates received an average of $9,022 (P = 0.001).
The Gag Rule
On the issue of the gag rule, AMPAC again contributed more frequently and more heavily to representatives opposing the AMA position (Table 3). During the 1989-1990 campaign, 91.3 percent of future backers of the gag rule received AMPAC funds, as compared with 85.6 percent of prospective opponents. Of those who received AMPAC funds, supporters of the gag rule received an average of $5,288, whereas opponents received an average of $4,850 (P = 0.22).
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When the contributions from 1989 through 1992 are considered, 100 percent of representatives who competed in the 1990 and 1992 elections and supported the gag rule received AMPAC funds, as compared with 95.3 percent of opponents. The AMA's opponents on this issue received an average of $10,961, whereas supporters received an average of $9,611 (P = 0.05).
The Public Health and AMPAC
During both election campaigns, AMPAC gave more to opponents of each of these three measures to protect the public health. It backed the representatives with the worst public health records in relation to the AMA positions (Table 4). In the period from 1989 through 1992, every House member who voted against the AMA positions on all three issues and who ran in the 1990 and 1992 elections received AMPAC funds, as did every House member who voted against the AMA on any two of the issues. Among members voting against the AMA on only one issue, 98.9 percent received contributions from AMPAC. Of representatives who agreed with the AMA on all three issues, 92.6 percent received contributions.
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Discussion
While the AMA was lobbying U.S. representatives to take strong stands on tobacco-export promotion, gun control, and the gag rule, its political action committee was supporting those who opposed its positions. Moreover, during the 1991-1992 campaign, as the pivotal votes were taking place in the House, the organization still backed those who opposed the AMA on these issues. On average, the more often a representative opposed the AMA on these three health-related issues, the more funds that member received from AMPAC.
There are several possible explanations for these results: methodologic, nonideological, and ideological. Some may suggest that these results can be explained by one of two methodologic limitations of our study. First, of necessity, we could compare AMPAC contributions to House members on one side of an issue only with contributions to members on the other side. In an ideal analysis we would have examined each congressional race individually and asked whether AMPAC supported the candidate with better positions on public health. Unfortunately, many losing candidates never took public stands on the three issues in question, making this ideal analysis impossible.
Our approach thus opens the door to the possibility that even though AMPAC contributed heavily to House members with positions counter to those of the AMA on these issues, the organization may still have supported the candidate with the best position in each district -- i.e., the "lesser of two evils." For example, if every House member opposed to gun control who received AMPAC funds had run against an opponent even more opposed to gun control, then AMPAC's funding decisions would have supported the AMA's official stance on the issue, and the results of our study would be misleading.
Yet we find it highly unlikely that most House members with positions opposed to those of the AMA faced opponents with more extreme beliefs. Moreover, if AMPAC had considered these issues seriously in making its contributions, one would expect to find it supporting more strongly House members who actually voted with the AMA positions. This did not happen in either of the two campaigns.
A second methodologic limitation is that our study did not account for the urgency with which House members may have needed funds from AMPAC. In the hypothetical case that most House members supportive of public health did not face serious opposition, they may have neither needed nor sought extra funds from AMPAC. According to this scenario, had they requested larger contributions, AMPAC would have gladly given them far more than it gave opponents of the public health side of these issues.
In assessing this limitation, it is important to recognize that the results of our study remained constant across two campaigns, including that for the 1992 election, a season of widespread anti-incumbent feeling when virtually all members were afraid of losing their seats. Moreover, AMPAC's support of the AMA's opponents on these issues was hardly lukewarm; in many cases, AMPAC spent the legal limit on candidates whose views ran contrary to those of the AMA.
We cannot discount these methodologic issues entirely, but it is useful to consider other, potentially more persuasive explanations. One nonideological observation is that contributions from AMPAC are intended not to support candidates who espouse specific views, but only to buy access. An editorial in the American Medical News described AMPAC's purpose as "encouraging and helping physicians and others to participate more actively and effectively in government affairs, to inform themselves about political issues, and organize for more effective political action"13.
Presumably, AMPAC contributed to nearly every representative so that doctors from all parts of the country could become involved in the political process. Yet this theory does not explain why AMPAC gave significantly more to representatives who disagreed with official positions of the AMA, or why AMPAC gave the most, on average, to representatives who voted against the AMA on all three health-related issues.
There are two possible ideological explanations. One is that AMPAC deliberately contributed to opponents of the AMA positions on the issues in order to persuade them to change their minds. If so, AMPAC certainly failed in achieving its goal. We find this possibility unlikely, because political action committees generally exist to support their friends, not their enemies. The second possible ideological explanation is that issues other than the three we studied led AMPAC to support candidates with anti-AMA records on these three issues. We searched for votes on other health-related issues during this period but found none that could explain AMPAC's support of these members. We doubt that there is another public health issue whose backers would tend to promote tobacco exports, oppose handgun control, and support the gag rule.
We are left with the possibility that AMPAC supported House members who backed the AMA on economic or political issues, or both, but tended to oppose the AMA on health-related issues. For this hypothesis to be supported, contributions from AMPAC would have to correlate with political positions that were themselves inversely correlated with votes on the three health-related issues. We found no clear votes on health care economics or policy in this period to use in such an analysis.
We did, however, find a general measure of political positions -- the 1991 vote ratings of the American Conservative Union (on a scale in which 0 denotes liberal and 100 conservative). After adding the rating for each representative to our data, we calculated the mean conservative ratings for members who had voted with the AMA on all three health-related issues (a rating of 16), on two issues (49), on one issue (71), and on no issues (87). The trend was statistically significant (r = -0.70, P<0.001). We also confirmed that from 1989 through 1992, AMPAC contributed significantly more to representatives with higher conservative ratings (r = 0.27, P<0.001). Thus, AMPAC tended to support political conservatives, who tended to vote against the AMA positions on public health issues.
What is it about political conservatives that earned them AMPAC's support? Our analysis cannot answer this question. Nor can it explain why AMPAC might have supported political conservatives over the public health allies of the AMA. Perhaps the more conservative representatives supported the AMA positions on economic issues important to physicians. Further analysis is needed to clarify the specific factors and issues that best predict AMPAC's contributions. In lieu of these studies, we believe it is important for all physicians to be concerned not only about the politics of the candidates they support, but also about their positions on major health-related issues.
We are indebted to Dr. Rick Parente of Towson State University and Dr. Marcia Testa of the Harvard School of Public Health for their advice on statistical analysis, to Dr. Paul Wise of the Harvard School of Public Health for his suggestions for data interpretation, and to Yngvild Olsen of Harvard Medical School for her assistance with proofreading and data checking.
Source Information
From Harvard Medical School, Boston (J.M.S.); and Sheppard and Enoch Pratt Hospital, Baltimore (S.S.S.).
Address reprint requests to Dr. Steven S. Sharfstein at Sheppard and Enoch Pratt Hospital, 6501 N. Charles St., Baltimore, MD 21204.
References
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Related Letters:
Contributions from the American Medical Political Action Committee to Members of Congress
Bristow L. R., Wilkerson J. D., Nadoolman W., Rothberg H. D., Dunsker S. B., Peters W. P., Sharfstein J. M., Sharfstein S. S.
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