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ChaPter 2 The Theory and Structure of Health Interest Communities in the States Politicians, media commentators, and scholars alike long have been concerned about the role of organized interests in public policy. Of particular concern is the seeming dominance of business over citizens and not-for-profit groups. In spite of this concern about the balance of different types of interest organizations in the population as a whole, the conversation in much of the media is about individual interest organizations. How is a given firm or association mobilized? What actions has it undertaken to influence public officials? And how influential is it? But there are limits to what we can learn by looking at one or a few interest organizations. Simply put, public policy is influenced by all of their actions in combination. Although we will see that some subsets of the interest population are at times more influential than others, we cannot get a comprehensive understanding of their overall influence on policy unless we address the full population of interests that might be engaged in influencing a related set of public policies. Within the past decade, the importance of a population-level focus fully emerged as political researchers and practitioners realized that features of an interest organization community—the balance of allied and opposed organizations , short-term coalitions of organizations, and competition between similar organizations, just to name a few—have a direct bearing on the organizational health, strategic behavior, and success of individual interest organizations (e.g., Nownes 2000; Nownes and Lapinski 2005; Baumgartner, Gray and Lowery 2009; Halpin and Jordan 2009; Messer, Berkhout, and Lowery 2011; Grossman 2012). The objective in this second chapter is to become more familiar with the features of the health interest organization communities in the American states and the theories and concepts that help us to understand their composition. This is a necessary first step in understanding how and why the several different configurations of interest organization communities studied in chapters 3 through 5 are likely to have diverse patterns of influence on health reform policy. 42 | CHAPTER 2 In chapter 2, then, we examine the structure of the health interest organization system in the fifty states using a population ecology approach, specifically, the Energy Stability Area (ESA) model of interest communities introduced in chapter 1. We begin with a brief introduction to the history of scholarship studying interest organizations as communities. We then present our data on the density and diversity of health interest groups operating in state capitals during the 1990s. The density and diversity data are examined in terms of both variation over time and variation across states. Finally, we present data that connect the population of health interest groups lobbying at the state level to the population of political action committees (PACs) operating in the same arena. The Study of Interest Organization Communities Scholars have developed three quite different explanations for the growth and composition of interest organization communities. Some provide a far more benign assessment of the effect of large and growing interest communities on policy and governance than others. Two of the three most prominent explanations of the growth of interest communities are firmly rooted in explanations of the mobilization of individual interest organizations. The first explanation was put forth by David Truman in his 1951 book The Governmental Process. He argued that interest groups form when like-minded individuals come together to address shared or common problems. In this view, mobilization, or the formation of interest organizations, is a natural and spontaneous response as citizens seek solutions to disturbances in their lives through public policy. To Truman, then, the eventual size of the interest community is limited only by the number and intensity of disturbances giving rise to the mobilization of new interest organizations . With greater social and economic complexity, the number and intensity of disturbances at least potentially amenable to public policy solutions grow. Therefore, if interest communities are becoming ever more crowded, then that is merely the result of a society that is growing increasingly complex. Of particular importance, Truman recognized but did not attend to interest communities per se. In his view all the interesting action occurs at the level of individual interest organizations and how they are mobilized. The interest community is generated merely through the accumulation of these mobilization events. And the size of this community changes with the frequency of disturbances, giving rise to the mobilization or demobilization of individual interest organizations. The second explanation of the density of...

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