Could Foundations Have Mounted A Better Defense of the Affordable Care Act?

Michael Booth, Researcher, writer and consultant in health care and nonprofits, after a 25-year career as a health care journalist with The Denver Post.

It came sometime after the “You lie!” outburst and the false claims of “death panels,” but before two potentially fatal US Supreme Court decisions and sixty-seven consecutive votes to repeal in the US House of Representatives.

In hindsight, President Obama’s signing of the Affordable Care Act (ACA) on March 23, 2010, was not the cheerful ending point that some might have expected. Rather, the ACA debate would play on long after, a center-stage feature for toxic partisanship that had begun years earlier.

What advocates and opponents alike called the most significant revolution in the American health care system since 1965 still required an actual launch. Medicaid expansion, insurance marketplaces, health information technology (IT) infrastructure, computing power, state legislation, bug-free software, and marketing outreach were all key steps—and critical targets. Yet even as advocates and lawmakers were struggling to build their new craft, opponents kept busy trying to tear it apart.

Given the ongoing vulnerability of the ACA, what could philanthropy have done differently to better support advocacy around implementation and help shore up this nascent law?

The Atlantic Philanthropies sought to explore what supportive funders did to advance the ACA’s odds of success following enactment. We focused on a mix of national funders and those that worked in selected states, including the Robert Wood Johnson Foundation, Community Catalyst, The California Endowment and The Atlantic Philanthropies itself. Had they prepared a plan for supporting the legislation after it was signed into law? Was there temptation to declare victory and move on to other issues? How should advocacy support have gone differently amid the hyperpartisan atmosphere that now surrounds health reform and other critical issues?

Q: If you could travel via time machine back to a funding meeting in your organization in 2008, during the run-up to health reform, how would you drive home the need for ongoing advocacy even after health reform became law?  

Michael Miller, Director of Strategic Policy, Community Catalyst: I would start by saying we would need to be more aggressive, more quickly. I think we understood by 2008 this was not going to be a cakewalk. In 2008 we still thought there might be some bipartisan support. But the rejectionist impulse was so strong that they said, we are going to obstruct it, we are not going to lift a finger to help it

The attack was so untethered from the facts that it caused a real circling of the wagons around the ACA among its supporters, and in a way that was more or less uncritical. There are challenges and limitations in the law, and no one wanted to acknowledge that because we didn’t want to add anything to the din of the attacks. One of the things we found is that with a lot of people, uncritical support of the ACA isn’t credible. If you target the middle of the electorate, you have to acknowledge where they are coming from. I mean, we’re thrilled that so many millions are on Medicaid and millions more are in the exchanges, but most Americans don’t get their coverage through ACA programs. And many Americans are paying a lot for their health care. We have to not just ‘Leave peoples’ health care alone,’ but deal with the expense.

Rob Restuccia, Executive Director, Community Catalyst: We could have made the legislation better; there are things baked into the structure of the ACA that created implementation challenges. Some of that might have been fixed if there had ever been a House-Senate conference committee on the ACA, but there wasn’t. One example would be the timeline, which I think was adopted in some ways for technical reasons, to say, “Let’s start enrollment as soon as they’re ready instead of waiting for 2013.” Start having positive stories to tell about this sooner rather than later. The fact you couldn’t move meant there was a prolonged period when the ACA was just an abstraction. And allowing the communications strategy to be dominated by Americans for Prosperity, I’m not quite sure how we would have done it differently, but we were set back five years by that. Most of the things they said about the ACA were just total lies. How were we not prepared for that?

Richard Figueroa, Director of Prevention and The Affordable Care Act, and Maricela Rodriguez, Program Manager, The California Endowment: For a thousand-page document, it was generally pretty well written. We would not have gone back to 2008 and said, “Make sure you have a good, functioning web site” – that wish was a given then, and is a given now. That’s a technological challenge, and not a challenge of writing the policy language.  We would have told President Obama for sure to never say, “You can keep your own doctor.” That was never going to be the case, given market changes.

Lori Grubstein, Program Officer, and Brent Thompson, Senior Communications Officer, Robert Wood Johnson Foundation: People were nervous, we’re putting so much money into this, what if it all unravels because of political contentiousness or the Supreme Court rulings? Many people believe the longer we have the ACA in place, the harder it will be to dismantle it, the benefits that millions and millions of people are now receiving.

We would stress the need to understand what you’re in for, in the partisan rough and tumble. We did, but other funders should think that through and know what their stomach is for that kind of stuff, and how’d they react in certain situations. Staying focused on the work and the benefits of the policy outcome to the mission of the organization — for us, it’s the health and health care of all Americans. We don’t really care about “the President’s precious law” or any phrases like that, we’re here to make sure Americans are covered. The institution has to be ready for that publicity, to be prepared for the possibility you’ll be called out, and some constituencies will not like what you’re doing and will take lots of shots at you. But that’s when it comes back to this: We’re not here to give the President victories or make the Democrats look good, we’re here to make sure people have help when they get sick. I think we were squarely within our mission at all times; but even then, there was a lot of soul searching for us: Is this too hot?

Steve McConnell, former Country Director for US Programs, The Atlantic Philanthropies: Atlantic was not a health care foundation when this started, not in the U.S. We said, “It’s possible that with a sympathetic president, there’s a chance to do something that hasn’t been done for 100 years.” But it didn’t have a home at the foundation, it was tacked on. The message is to not avoid doing things that don’t have a home. It’s a shame not to be opportunistic when these things pop up.

I’d tell them it’s really admirable we’re making this big bet on something that’s not clearly part of our program areas. So let’s set up a group of people not only focused on the legislation, but who will look at the things that will be needed if the legislation passed. The risk is it might have scared people away. “Gee, I thought $25 million would be enough and now you’re telling me we need $10 million or more for implementation.” We would not have been caught flatfooted. We could have done a better job being prepared for the implementation phase.

Q: Did your organization discuss its potential role in advocacy for ACA implementation as the law was being shaped, and ultimately passed, by Congress? Should you have put more thought into how post-passage advocacy might play out?

Steve McConnell: We should have planned more. “Let’s say we get lucky, what then?” It was a struggle getting resources to do this work. That’s the lesson from any of this work. In any legislation, there’s an implementation phase that goes on forever. You can get it passed today and they’ll try to take it away tomorrow — the Republicans have voted to take away the ACA what, more than 60 times now? So whatever you are doing, there’s a short term set of things and then a longer term set of things that may be even more important.  Passing the legislation is now looking like it was the easiest part.

Lori Grubstein and Brent Thompson: When there seemed to be this open window for national health reform, of course we were very focused on that. Then when the ACA was enacted, we felt the most logical thing we could do was support implementation. Our goal was to make sure the ACA was implemented in a high-quality way. For us, that was making sure it was done in a very consumer-friendly way. We were mainly funding implementation at the state level. I think we put a good deal of time into planning, so I wouldn’t say we could have done a lot more.

Richard Figueroa and Maricela Rodriguez: We knew from the beginning that enrollment was the hardest thing you can do. California does not have a good record on that in social services programs. Once the Medicaid expansion was signed into law, the California government had not wanted to spend any money to tell people about it; so we stepped in and put tens of millions of dollars into the state department in charge of enrollment. We basically became the state’s marketing arm. It’s very unusual for a foundation to directly write checks to government for these purposes, but it’s the most effective way to get the federal match, and the administration was not keen on spending their own money. Separately, we took on a very large-scale media campaign around the state.

Q: What specific strategies do you believe were effective during the ACA implementation stage, and which were in retrospect not effective? For example, many pro-ACA groups believed that “storytelling” focused on personal anecdotes would build support and win over policy makers.

Richard Figueroa and Maricela Rodriguez: We knew where the foundation could help the most: The Latino population of California. There was no comparison to any other ethnic group in terms of the number of uninsured people we could reach. We did do our homework, we found the best way to reach Spanish-speaking communities and Latinos in general was through Spanish television and Spanish news. So we formed Spanish media partnerships, and for the first three years that partnership spent about $20 million

The state had figured it might get 1.2 million people coming in through the expansion; we had set a stretch goal of 2 million people, trying to double what the state estimated. Well, we’re at 3.5 million and still going, so it way surpassed anything anybody could have imagined. When this process started we were at 8 million people in Medicaid, now we’re over 13 million, or about a third of all Californians are in our Medicaid programs.  We’d like to think we played some role in making sure that information penetrated far enough in the community that people were willing to come in, to create buzz and a culture of coverage.

The Spanish-language media operates differently than English-language media, which try to be in the middle and not have an opinion about things. Spanish-language media views themselves as part of the community. They can have an attitude and an opinion about things, and they were very strongly in favor of getting more coverage for folks. They really took it to heart and really made it their thing for at least a whole year. 

Sara Kay, former Health of Advocacy and Health Equity Programs, The Atlantic Philanthropies: I’d say we learned smarter storytelling. With all due respect to colleagues in communication, even in “Hillarycare” there was a lot of storytelling about uninsured people with sad, sad personal stories. We learned through research that what that did was trigger loss-aversion among middle class people who already had insurance. It didn’t make them more compassionate, it only made them very happy to not be uninsured. I do think we got much better at understanding what voters need to hear about is, what’s in it for me. And that’s a different kind of messaging. And it couldn’t be painted as a poverty program, even if in many cases that’s what it ended up being through Medicaid expansion. But if the messaging had become about “free-riders and poor people,” that would have been a killer on the messaging side.

Q: Do you feel the deep partisanship for seven-plus years now has altered your organization’s view of funding other high-profile policy questions such as immigration?

Lori Grubstein and Brent Thompson We were supporting coverage efforts since our founding in the 1970s; folks here were used to the contentiousness of this issue. This foundation was also a very significant player in the player in the health care policy debates of the mid-1990s, so we were intimately aware of the partisan nastiness that can go along with health care reform. We didn’t relish it, but it was not a surprise to us. It may influence specific tactical decisions but not the overall strategy. We are very cognizant that we maintain our reputation as being nonpartisan and try to rise above the politics. And we always have a very balanced portfolio of things we’re funding and try to make sure whatever we’re funding is mission-based, and that we’re trying a lot of different perspectives.

Steve McConnell That’s something I love about Atlantic: It has no fear. I went to the board at the end of 2012 and said it looks like we have an opportunity to work on immigration reform, and I’d like $10 million to invest in C4 efforts. And they said, fine. It was a worthwhile thing to do. Atlantic always had this notion it should make bold bets: The board really wanted us to make big bets, and the founder wanted us to make big bets, and not do “sprinkle” philanthropy.

Sara Kay – Have we learned anything about dealing with people who are unconstrained by the truth? I don’t know that any of us were prepared for that. There’s another health funder I work with, a woman who works in a deep red state. She called and asked for help in thinking through some of her strategies a couple of years ago. She said, “You know, I used to fund advocacy, but now the advocates can’t even get in the door with their state elected officials. So then I started funding objective research, and now they don’t even care what the research says. So what do I fund?” It’s a very hard question that I don’t think is limited to health care. Some people say that maybe funding get-out-the-vote is your only hope. 

Rob Restuccia – We’ve created a C4 and strengthened our campaign capacity on that as a result; I’ve been doing this for 30 years and I used to tell people that we just had to tell the truth as a consumer advocate and you’ll win. That’s not true anymore. You have to be much more political, you have to be much more cognizant of the political dynamic, and you’re going to be fighting off opposition that is much better funded.

Montana is an example. We funded advocates there to help fight Americans for Prosperity around Medicaid expansion. It was David vs. Goliath, and David won. We gave them not just money but support around strategy, and technical assistance. The governor of Montana ended up thanking us. Wehave really shifted in thinking to being much more aggressive on that spectrum of activities, from C4 to civic engagement, and be willing to challenge our opposition or support other organizations that challenge the opposition.

Richard Figueroa and Maricela Rodriguez — We’ve never been afraid to take on difficult challenges. We’re lucky to have a supportive board, and lucky to have the resources to do this work. We said at the beginning, if we don’t exist to do these things, then why do we exist? 

We were the only foundation in the country that actually filed an amicus brief with the Supreme Court in favor of the ACA. We didn’t really have a Plan B. We assumed they would do the right thing, and we were go-go-go the whole time. It’s pretty difficult for a state to go alone and fund these things, especially with such a large group of Medicaid eligible. We did put all our eggs in one basket, knowing that this was the largest change we were going to see in the health care coverage system in our lifetimes. Who knows when we’re going to see the next one? In fact our success on the Medicaid side has continued to fuel our interest in Health for All, which is very controversial, but it is working to get everybody covered. Heck, we’re going for covering the undocumented, and there’s nothing more controversial than that.

Although foundations had remarkably varied experiences in their advocacy support of the ACA, the lessons for the wider philanthropic community are clear: when complex political and social issues like health reform are caught up in partisan battles, the need for advocacy support persists well beyond a policy win. Whether in health care (or in looming and ongoing debates about climate change or immigration reform), a hyperpartisan environment leaves little separation between advocating and implementing. That’s because political fights don’t really have a beginning and end anymore, and neither do most policy debates.

For foundations, this leaves a sometimes tricky playing field, where debate is not always tied to facts and where policy change is not always secure. But foundations can prepare and provide advocacy support accordingly, by keeping advocacy investments and funding goals closely tied, by bringing their boards along as stalwart allies, and, when initial success occurs, looking to expand support rather than retrenching or retreating.

Getting to the win is often not the end, but rather the start of the next push forward.

This article was commissioned by the Center for Evaluation Innovation, as part of the Atlas Learning Project, with support from The Atlantic Philanthropies.

It was originally published on Health Affairs GrantWatch Blog.

Michael Booth is a researcher, writer and consultant in health care and nonprofits, after a 25-year career as a health care journalist with The Denver Post. He is co-author of the 2015 Colorado Book Award for Nonfiction, “Eating Dangerously: Why the Government Can’t Keep Your Food Safe . . . and How You Can.”