The health care influence industry -- its well-connected players, its high-dollar ad campaigns and its massive lobbying expenditures -- is facing heightened scrutiny as the congressional health care debate intensifies.

Second-quarter lobbying reports show that 22 groups related to health care spent at least $1 million on lobbying in a three-month period, and several spent considerably more.

Top players include the Pharmaceutical Research and Manufacturers of America (PhRMA), which reported $6.2 million in lobbying expenditures; Pfizer, which laid out $5.6 million; and the American Medical Association, which spent $3.9 million. That landed all three in the top 10 of lobbying spenders in the second quarter, according to a tally by NationalJournal.com's Under The Influence blog.

Democrats enjoy close ties with influential players in the health care lobbying world.

That spending followed a fast-paced first quarter for the industry. Overall, health care interests invested $126.8 million in lobbying over the first three months of this year, according to the nonprofit Center for Responsive Politics, placing it well ahead of any other sector. "It blows away the ideological and single-issue groups," noted CRP spokesman Dave Levinthal.

Health care-related TV advertising is also soaring. Spending through July 20 totaled $39 million, according to the Campaign Media Analysis Group, which tracks spending on TV ads nationwide. That includes a jump of $8 million over a three-week period, the group reported.

Players unrolling major ad campaigns recently include America's Health Insurance Plans; the progressive group Health Care for America Now, and the U.S. Chamber of Commerce. Even the Democratic and Republican national party committees have weighed in with ads that respectively promote or oppose a health care overhaul.

Big spending on health lobbying is nothing new, of course. Since 1998, the health sector has put $3.4 billion into lobbying efforts, according to CRP, ranking second only to the financial industry in lobbying expenditures.

But spending has spiked since the beginning of last year, particularly among deep-pocketed organizations with a major stake in the health care debate. Since January 2008, for example, three industry groups have invested at least $20 million each on health care lobbying, according to CRP: PhRMA, the American Medical Association, and the American Hospital Association.

Health care lobby groups have been generous with their campaign contributions, too, particularly to Democrats. In the first three moths of 2009, Democrats collected 60 percent of the $5.4 million in health care sector campaign donations, according to CRP -- a reversal of a previous trend.

Democrats also enjoy close ties with influential players in the health care lobbying world, according to the Sunlight Foundation, particularly those lawmakers sitting on committees with a key role in the legislation. One senator receiving attention lately for his health care lobbyist friends is Democrat Max Baucus of Montana, who chairs the Senate Finance Committee.

Five of Baucus' former staff members now work for a total of 27 different organizations that either represent the health care or insurance industries, or have a vested interest in the debate, according to a Sunlight Foundation analysis of lobbying disclosure filings.

"We thought it was important to show the public that the senators aren't crafting the policy by themselves," said Sunlight Foundation senior writer Paul Blumenthal. "They have all these other connections, through relationships, that have a huge stake in this legislation."

To avoid the appearance of a conflict, Baucus in June began refusing contributions from health care political action committees. However, he still takes donations from health care lobbyists and executives.

The parade of health care lobbyists visiting the White House also moved into the spotlight last week, thanks to a lawsuit filed under the Freedom of Information Act by Citizens for Responsibility and Ethics in Washington. The ethics group had demanded White House visitor logs.

The White House complied in part, offering up an unofficial list showing visits from AHA President and CEO Richard Umbdenstock; PhRMA President and CEO Billy Tauzin, the former congressman from Louisiana; and Karen Ignagni, president and CEO of AHIP, among others. None of the health care lobbyist visitors was a major Obama campaign donor.

CREW objects that the White House still has not complied with its FOIA request, since administration officials released a discretionary list as opposed to handing over requested public records.

It's been more than 15 years since the health insurance industry's notorious "Harry and Louise" ads were credited with bringing down the Clinton administration's proposed health care overhaul. It's unlikely that any one ad or industry group will be singled out in quite the same way if reform efforts fail this time around.

But if gridlock triumphs yet again, it's fair to say that the well-funded, well-connected health care lobbying complex will shoulder at least some of the blame.

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