AcademyHealth
State Health Research and Policy Interest Group
February 8, 2011
Meeting Summary
The State Health Research and Policy Interest Group (SIG) met on February 8, 2011 in
conjunction with AcademyHealth’s National Health Policy Conference in Washington,
DC. The meeting was sponsored, in part, by The Commonwealth Fund, the Georgia
Health Policy Center, the National Academy for State Health Policy, and the Robert
Wood Johnson Foundation’s State Coverage Initiatives.
As attention is shifting to the challenge of state-level implementation decisions where
increased public scrutiny requires ongoing efforts to engage and inform the public, the
SIG developed a breakfast meeting to address some of these implementation challenges.
The meeting began with an overview of what recent polls tell us about the public's
knowledge and opinions of the Affordable Care Act. Next, the meeting focused on the
Oregon story—looking at the communications strategies undertaken as part of the statebased health reforms that were enacted in 2009, as well as ongoing efforts to engage
consumers in the formulation and implementation of state and federal health policy.
Finally, a communications expert who has been working with states and the federal
government highlighted critical factors for strategic messaging and effective public
outreach.
The first panelist, Humphrey Taylor, Chairman of The Harris Poll, spoke about the
latest polling results for the Patient Protection and Affordable Care Act (ACA). He noted
that – at a high level – the results indicate that the complexity of the ACA makes it
confusing to the public, that people are conflicted, because they favor contradictory
policies, that they don’t know or understand the various component of the law, and that
they feel that the federal government hasn’t produced a reform bill they like.
Taylor then presented the poll numbers in more detailed snapshots, which painted a
picture of a very divided public. Based on Harris Poll data from December 2010, 40
percent of respondents said that they wanted to repeal the ACA either in whole (28%) or
in part (12%), while 31 percent said they wanted to keep the ACA in whole (6%), in part
(9%), or add more reforms to the law (16%). 29 percent of respondents answered that
they were not sure whether they wanted the law to be kept or repealed. Party
identification, not surprisingly, greatly influences whether respondents want the ACA to
be repealed or not. Only 12 percent of self-identified Democrats support repealing the
law, with 37 percent of self-identified Independents and 69 percent of self-identified
Republicans supporting repeal.
As the Harris Poll delved more deeply into the opinions of the 40% of respondents who
wanted to repeal all or part of the ACA, it became apparent that their opinions – for the
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most part – were based on information they had heard in the media that was not entirely
accurate. For example, the number one response from this group, at 82 percent of
respondents, was that they wanted the law repealed because it is a government takeover
of the health care system. Other frequently mentioned responses were:
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Too expensive: 81%
Higher taxes: 81%
An expansion of big government: 80%
It will reduce the quality of health care received: 77%
It is a rationing of health care: 74%
It is a form of socialism: 71%
When the Harris Poll asked people about specific provisions of the ACA, and whether
they would want to keep or repeal those provisions on an individual basis, majorities or
pluralities of respondents indicated that they wanted to keep each mentioned provision.
The only exception to this polling was for the individual mandate, with 19% of
respondents saying they wanted to keep that portion of the law, 57% wanting to repeal it,
and 25% not sure. Taylor noted that effective communication around this provision – that
everyone has to purchase insurance or pay a penalty – is crucial if states hope to influence
their public’s opinions on the ACA in its entirety.
Polling data has shown that there is considerable confusion about what is included in the
ACA, and how it will change the delivery system and insurance markets in the United
States. For example, only 58% of those polled knew that the ACA will not allow insurers
to deny coverage to people because they are sick moving forward, despite the focus
placed on communicating that benefit of the law to the public.
In conclusion, Taylor noted that when it comes to influencing opinions, effective rhetoric
trumps actual information, ideology trumps substance, and partisanship trumps almost
everything.
The second presenter, Bruce Goldberg, M.D., Director of the Oregon Department of
Human Services and Director of the Oregon Health Authority, discussed Oregon’s
history with health reform and public engagement and input on reform, which started as
early as the 1980s. In the 1990s, the state redesigned its Medicaid program, a process that
was rooted in surveys of community values, public meetings across the state, and citizenled, public commissions that made decisions in a transparent manner.
The state’s most recent reform activities started in 2007. This process began with the
state Senate Committee on Health Reform holding public hearings during the 2007
legislative session. Senate leadership traveled throughout the state to the public as well,
instead of only hearing from those individuals with access to the state capital. As a result
of these different meetings, the Committee began to craft a plan for reform, establishing
the citizen Oregon Health Fund Board as the entity to develop a health reform plan for
the state.
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The Oregon Health Fund Board – composed of 7 Oregonians – held over 100 public
meetings to gather public input, organized coalitions of advocates, and also
commissioned statewide polls to gather data that could be used to identify important
themes. A final report was then submitted to the legislature, analyzing the public
stakeholder input and feedback from this statewide process.
As a result of this work, in 2009 an omnibus health reform bill passed the Oregon state
legislature, which laid out a series of steps for implementing the reforms, including the
establishment of a citizen-led Oregon Health Policy Board, ensuring public engagement
and input throughout the implementation process.
Dr. Goldberg next detailed some key lessons Oregon learned during this period of
stakeholder engagement:
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A public process, outside of the legislative process, is vital for success.
Transparent decision making led by and involving the general public can be an
effective way to change public policy.
Do whatever is needed to go where the public is, instead of expecting them to
come to you in the capital. Focused and determined outreach to individuals and
local groups, such as chambers of commerce or Rotary Clubs, is a central
component of this work.
Structure and consistency is key. The state needed an infrastructure to organize
stakeholders, and to create a consistent message. It used partners to get the
message out and used those partners as a vehicle to receive information from the
public. The message needs to be repeated and delivered multiple times, and the
feedback loop from the public needs to be continuous, and allow for updates of
information, as opposed to a one-shot opportunity.
Inviting people in and allowing stakeholders to develop proposals for how to
move forward is important. In Oregon, committees of stakeholders developed
recommendations to boards, and those proposals were vetted through committees
and again through board. The recommendations were made public, and input was
obtained before board’s final action and decision.
Regular and accessible communication, using different modalities, can be a
powerful way to share progress and the status of any reform effort. Oregon had a
monthly email bulletin that went out to 10,000 individuals, streamed all of its
public meetings live, and employed social media such as Facebook, Twitter, and
YouTube. A web survey tool was also available to the public as a way for them to
provide input.
Crafting the message so that it is personal and local helps it resonate with the
public. Oregon framed its messages so that they referred to “local Oregon values,”
and told stories using local Oregonians to drive the message home to the public.
Highlighting your successes through stories and talking about what works allows
the public to learn about the positives of any reform, and helps gain their support
and trust.
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The final presenter, Alison Betty, Senior Vice President of Greer Margolis Mitchell
Burns (GMMB) – Communications Firm, discussed the insights her firm has discovered
through focus groups, an online listening project, and Harris Interactive / HealthDay poll
data from February 16 – 18, 2011. Overall, the results of these activities have been that in
order to be effective, states’ communications around ACA should be straightforward and
demonstrate, as simply as possible, how the law benefits individuals. Additionally, to be
effective states should have the messages come from trusted sources of information,
including nurses, doctors, small business owners, and other state residents. These
individuals will have had first-hand experience with the benefits of the ACA.
Ms. Betty included sample messages that testing has shown to be effective. Those
messages are listed below:
Cost and Affordability
Making sure everyone has health insurance reduces health care costs for the rest of us.
Currently, when someone who is uninsured gets sick and can’t pay, those of us who have
insurance have those costs shifted onto them (which costs more than if we simply helped
people afford insurance). Requiring the uninsured to get insurance – and even helping
to pay for those who cannot afford coverage – is less expensive for those of us who are
insured than paying the cost of care for the uninsured.
Pre-existing Conditions
Currently, insurance companies have decided who gets covered and who does not. As a
result, millions of Americans have been denied the coverage they need simply because
they have a preexisting health condition, like asthma, diabetes, or cancer. Beginning in
2014, this discrimination will end and insurance companies will be required to cover
everyone, even those who have a preexisting condition. But it only works if everyone
is required to get insurance. If we allow people to wait until they get sick or have an
accident to buy insurance, the cost of health care will continue to skyrocket for
everyone one else.
Preventive Care
Affordability and coverage go hand-in-hand. Forcing insurance companies to make
quality health care affordable will mean more than 30 million previously-uninsured
Americans will have access to coverage. And that means we all get the high quality,
comprehensive coverage we need, including no denials for preexisting conditions and
coverage for preventive care like cancer screenings and wellness checkups.
Moving Ahead with Reform Despite Repeal Efforts
While insurance premiums have doubled on average over the last 10 years, and hundreds
of thousands of our residents are unable to afford any health insurance at all, the only
responsible thing to do is continue our work to make health care more affordable
and accessible. That is why state officials and health providers are working not only to
meet the requirements of the current federal law, but they are also using newly available
federal funds to create programs and policies that are designed specifically to meet
the needs of our [STATE’s] health system and its residents. Regardless of what
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happens to the federal reform law in coming years, [STATE] is moving forward with an
open and transparent process to lower costs, increase access and improve the quality of
care for all residents.
Despite Current State Budget Cuts
We understand that [STATE’s] immediate task is to balance the budget and keep the state
moving. But, we should not be short‐sighted and ignore the opportunity created by
health reform to improve our health care system and make it more efficient. For the long
term health of [STATE’s] finances and its residents, we need to transform our health care
system so that it provides quality, affordable care to more people while reducing
waste and inefficiencies.
Health Insurance Exchanges
The [STATE] Health Insurance Exchange will serve as a one‐stop shopping website
where residents can compare both public and private health coverage options and make
decision on the plans that work best for them and their families. Private insurers will
compete for their business in a fair and completely transparent marketplace where
consumers will have the opportunity to compare rates, benefits and quality among
plans to help find the one that best suits their needs. All Members of Congress will get
their health insurance through the exchange as well.
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