Steadily rising healthcare costs coupled with diminishing access to insurance has Americans asking why—and what can be done about it. In his new book, Pre-Existing Conditions: How Lobbying Makes American Healthcare More Expensive (out today from Oxford University Press), Alex Garlick, Ph.D., offers some answers.

Garlick, an assistant professor in the Department of Political Science at the University of Vermont, draws back the curtain on the secretive process of lobbying and how it affects one of the most pressing contemporary policy issues: healthcare inflation. We sat down for a conversation with Garlick about the book, his findings, and their implications. 

College of Arts and Sciences: Where did you get the idea for this book? 

Alex Garlick: I worked in Congress in 2017 on a one-year fellowship in the first Trump administration when they were trying to repeal and replace the Affordable Care Act. I had done a lot of research on interest groups as a grad student, but actually being in Congress allowed me to see how much influence there was from lobbyists on the congressional agenda. It made me look back at my research and try to understand how the academic consensus on lobbyists was underestimating their impact. 

The other major takeaway from that time was how the healthcare industry in particular affects the decisions of policymakers at both the national and state levels. We see a lot of different outcomes from state to state, so it was worth looking at what tools state policymakers use to try to rein in costs. 

CAS: Who are the main healthcare lobbyists? 

AG: The top three are hospitals, pharmaceutical manufacturers, and insurance companies. Then there are the professional associations of healthcare providers and the patient advocates. 

The complicating factor is that some major companies have started to transcend those categories. We’ve seen the emergence of major regional healthcare networks that have almost a monopoly on their local healthcare markets, which means they can dictate prices for insurers and patients. And there’s not a lot of push-back because those patients and insurers have nowhere else to go. 

Another evolution has been the emergence of behemoth companies that combine health insurance business with retail pharmacies and pharmacy benefit managers. We’re also seeing an increase in private-equity firms owning for-profit hospitals and physician practices. 

CAS: Why is the lobbying process so opaque?

AG: There’s a mutual interest for both legislators and lobbyists to keep these interactions in the shadows. Lobbyists are aware that the public is skeptical of their motivations and their interests. Legislators are aware that their voters do not want them giving in to lobbyists, especially when those legislators stand for election. 

There have been efforts to improve transparency. The empirical data in the book is largely based on lobbying registrations—requirements that firms that lobby and hire lobbyists must disclose how much they’re paying, what states they’re operating in, the subjects of their lobbying, etc. So, we understand this better than we have in prior decades, but it’s still a fairly opaque process, even when it’s done legally. 

CAS: In the book you note that healthcare is uniquely situated to satisfy the conditions that make lobbyists more likely to be influential. Why is that?

AG: When it comes to healthcare, cost-containment policy isn’t well known, and it’s complex. The public and media have more difficulty engaging with these kinds of topics. This is where lobbyists thrive.

Lobbyists ultimately traffic in information—their ability to help a legislator understand an issue or a new policy. That’s what gets them in the room with legislators and gives them their influence. So, when things are more complex, it helps lobbyists because it makes their information more valuable. 

Healthcare is a very complicated subject. Many people need advanced degrees and years of experience to understand these issues. Many legislators, who are often lawyers, don’t have that experience or expertise. Therefore, they need to rely on someone to explain it to them. 

CAS: You say in the book that the outlook for a fundamental reform of America’s healthcare system looks bleak. Why? Are there any examples of victories?

AG: The Trump administration’s current priorities in healthcare are more about cutting costs and cutting access to healthcare, specifically through Medicaid, than expanding them. So, before we talk about reforming healthcare with the goal of expanding access or lowering cost, stopping the reduction of access to healthcare would probably be the first priority. 

CAS: Are there any examples of victories in the area of healthcare reform?

AG: In the book, I wrote about out-of-pocket caps for insulin. I think that is a fairly modest reform, but it’s an example of a policy issue that was able to break through some of the barriers. Patient advocacy groups, like the ones I document in Colorado and Minnesota, were able to rally public support behind this idea that insulin should not be so expensive, and it should be available to everyone. 

Can that model be expanded to other parts of the healthcare financing agenda? That remains to be seen. But you can see a blueprint of sorts there for how to take on the pharmaceutical companies. 

CAS: Is there anything the average American can do to encourage change in healthcare legislation?

AG: The first thing Americans need to think about is how important this issue of healthcare financing has become. The second thing is to think about what can be done about it specifically, whether it’s prices that providers are charging at hospitals or the cost of drugs. 

We can look at states that have had successes and think more about how those can be replicated. Also, people can encourage their legislators and policymakers to be more transparent. The representatives at both the state and national levels should represent the people and not narrow interests. And one way to ensure that they are representing the people is to shed as much light on the process of lobbying as possible.

I think the book lands at an important time, when people are paying attention to these issues. The concerns they have now are only going to heighten and become more pertinent as the next election heats up.