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In 2010, before the Affordable Care Act was passed by Congress, the pharmaceutical industry's top lobbying group was a very public supporter of the measure. It even helped fund a multimillion-dollar TV ad campaign backing passage of the law.
But last year, when Republicans mounted an aggressive effort to repeal and replace the law, the group made a point of staying outside the fray.
"We've not taken a position," said Stephen Ubl, head of the organization, the Pharmaceutical Research and Manufacturers of America, known as PhRMA, in a March 2017 interview.
That stance, however, was at odds with its financial support of another group, the American Action Network, which was heavily involved in that effort to put an end to the ACA, often referred to as Obamacare, spending an estimated $10 million on an ad campaign designed to build voter support for its elimination.
"Urge him to repeal and replace the Affordable Care Act now," one ad running in early 2017 advised viewers to tell their congressman. That and similar material (including robocalls) paid for by the American Action Network ran numerous times last year in 75 congressional districts.
PhRMA was one of AAN's biggest donors the previous year, giving it $6.1 million, federal regulatory filings show. And PhRMA had a substantial interest in the outcome of the repeal efforts. Among other actions, the GOP-backed health bill would have eliminated a federal fee paid by pharmaceutical companies, one estimated at $28 billion over a decade.
But there was no way the public could have known at the time about PhRMA's support of AAN or the identity of other deep-pocketed financiers behind the group.
Unlike groups receiving its funds, PhRMA and similar nonprofits must report the grants in their own filings to the Internal Revenue Service. But the disclosures don't occur until months or sometimes more than a year after the donation.
The conservative-leaning AAN has become one of the most prominent nonprofits for funneling "dark money" -- difficult-to-trace funds behind TV ads, phone calls, grass-roots organizing and other investments used to influence politics. Such groups have thrived since the Supreme Court's Citizens United decision in 2010, which loosened rules for corporate political spending, and amid what critics say is nonexistent policing of remaining rules by the IRS.
(It's impossible to know from public records whether PhRMA donated before or after President Donald Trump's victory, which made repealing the health law a substantial possibility. In any case, most donations to dark-money groups are not earmarked for a particular program.)
Generally speaking, dark-money groups are politically active organizations, often nonprofits, that are not required to disclose identities of their donors. Under IRS regulations, donors may fund a nonprofit group such as AAN, which is allowed to engage in political activities and is not required to reveal its funding sources.
Dark-money groups are often chartered under Section 501(c)(4) of the tax law, which grants tax exemption to "social welfare organizations." For those seeking to influence politics but stay in the background, 501(c)(4) designations offer two big advantages: tax exemption and no requirement to disclose donors.
Against the backdrop of high drug prices and its heaviest political expenditures in years, the pharmaceutical industry is directing substantial resources through AAN and other such groups that hide the identity of their donors and have few if any limits on fundraising.
"PhRMA has always been very aggressive and very effective in their influence efforts," said Michael Beckel, research manager at Issue One, a nonprofit devoted to campaign-finance transparency. "That includes using these new, dark-money vehicles to influence policy and elections."
PhRMA's $6.1 million, unrestricted donation to AAN was its single-biggest grant in 2016, dwarfing its $130,000 contribution to the same group the year before. Closely associated with House Republicans -- AAN has a former Republican senator and two former Republican House members on its board -- the group backed the failed GOP health bill intended to replace the Affordable Care Act. It also supported the successful Tax Cuts and Jobs Act of 2017, which reduced corporate taxes by hundreds of billions of dollars over a decade.
So far in this election cycle, AAN has given more than $19 million to the Congressional Leadership Fund, a Republican super PAC with which it shares an address and staff, according to the Center for Responsive Politics. The fund recently ran ads opposing Democratic candidates in high-profile special congressional elections in Georgia and Pennsylvania.
PhRMA disputes the suggestion that it backs particular actions by the recipients of its donations. "PhRMA engages with groups and organizations that have a wide array of health care opinions and policy priorities," said its spokesman, Robert Zirkelbach. "It is inaccurate and would be inappropriate for you to attribute those grants to a specific campaign."
AAN declined several requests for comment.
Including AAN, PhRMA gave nearly $10 million in 2016 to politically active groups that don't have to disclose donors, its most recent filing with the IRS shows. By contrast, PhRMA and its political action committee, or PAC, made only about $1 million in comparatively transparent political donations in 2015 and 2016 that were disclosed to regulators and reported by the Center for Responsive Politics.
PhRMA's 2016 political activities included support for the Republican National Convention. Rather than directly support the Cleveland convention, which several companies pulled out of after it became clear that Donald Trump was going to be the presidential nominee, PhRMA routed $150,000 through limited liability companies with names like Convention Services 2016 and Friends of the House 2016.
Like 501(c)(4)s, LLCs do not have to disclose their donors. PhRMA's support was revealed in IRS filings more than a year later. (Donations by PhRMA and other groups to Friends of the House, which financed a luxury lounge for convention dignitaries, were first reported by the Center for Public Integrity last fall.)
PhRMA's surge in donations to AAN coincides with the arrival of Ubl, who took over as president and CEO in 2015 and has long-standing ties to Norm Coleman, a former U.S. senator from Minnesota who is now AAN's chairman. Ubl once ran the lobby for makers of knee implants, heart stents and other medical devices, one of whose most powerful members, Medtronic, is based in Minneapolis.
Dues paid by member drug companies rose by 50 percent after he got there. PhRMA's total revenue increased by nearly a fourth in 2016, according to IRS filings.
PhRMA's 2016 dark-money contributions included $150,000 to Americans for Prosperity, a conservative group associated with billionaires Charles and David Koch. Their group has already signaled it will be active in November's elections, running attack ads against Sen. Jon Tester, a vulnerable Montana Democrat, for not supporting ACA repeal.
PhRMA also gave $50,000 to Americans for Tax Reform, run by conservative anti-tax activist Grover Norquist.
PhRMA and other trade associations donate to such groups "to avoid attracting attention" amid the political fray, said Bruce Freed, president of the Center for Political Accountability, which seeks to shed light on corporate political spending. Nevertheless "they're achieving their goals by giving money to these folks and helping elect members that are going to be in support of them."
Mostly smaller amounts went to centrist and liberal groups. Center Forward, which claims to seek bipartisan, common ground on drug policy and other issues, got $300,000 directly from PhRMA and another $179,000 from a PhRMA-backed group called the Campaign for Medical Discovery, according to tax filings.
Zirkelbach disputed the notion that PhRMA donations to AAN and other groups were intended to achieve specific goals, saying, "We seek to work with organizations we agree with as well as those where we have disagreements on public policy issues."
Much of the work by PhRMA-linked, dark-money groups touches health policy and harmonizes with PhRMA's positions.
During debates over the tax overhaul, Center Forward worked to preserve a tax credit for researching rare-disease medicines known as orphan drugs. PhRMA took a similar stance, encouraging Congress "to maintain incentives" for rare-disease drugs.
AAN, which collected total contributions and grants of $14.6 million for fiscal 2016, launched a $2.6 million mass-mailing and ad campaign against letting Medicare lower drug prices through negotiations. PhRMA supported that stance, telling Healthline that such a measure could jeopardize seniors' access to medicine and discourage companies from developing drugs.
Americans for Tax Reform ran similar ads in local markets opposing "price controls" on prescription drugs.
PhRMA's dark-money allies push its agenda without disclosing its role, critics say.
PhRMA is "spending millions of dollars on politics every cycle, and they're splitting it up between the state and federal level," said Robert Maguire, political nonprofits investigator for the Center for Responsive Politics, which tracks political donations. "They're just not running the political ads themselves," which keeps their name off the product, he said.
A group called Caregiver Voices United, which got $720,000 from PhRMA in 2016, backed a secret effort to generate letters opposing a drug-transparency bill in Oregon. The campaign surfaced when an employee leaked phone-script documents to a lawmaker, as reported in February by The Register-Guard newspaper in Eugene.
Caregiver Voices United is "not influenced" by PhRMA or any other outside group, said John Schall, its president.
Dark-money groups received pharmaceutical industry money from individual companies as well, not just the PhRMA trade organization.
In 2016, Amgen gave $7,500 to Third Way, a center-left group that supports reimbursement for drugs and medical devices based on their results, according to the Center for Political Accountability. Johnson & Johnson gave $35,000 that year to the Republican Main Street Partnership, a 501(c)(4) that describes itself as a coalition of lawmakers committed to "conservative, pragmatic government," the CPA data show.
But CPA's research also reveals that many pharmaceutical companies don't disclose donations made to 501(c)(4) organizations, nor are they legally required to.
Corporations "could dump millions into one of these (c)(4)s and nobody would ever know where it came from," said Steven Billet, a former AT&T lobbyist who teaches PAC management at George Washington University.
KHN's coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
