Early Lessons from Oregon's 2002 Measure 23 Campaign
by Mark Lindgren, Chair, Health Care for All-Oregon
Our experience in Oregon provides both a positive example of how much an under-funded, volunteer-based health care campaign can achieve, as well as the limitations of this approach. Volunteers collected most of the 98,000 signatures needed to place the initiative on the ballot (we did pay for signatures at the end of the signature-gathering phase, to ensure its success). After an October 11 poll showed a virtually dead heat, the insurance industry tripled its spending to at least $1.2 million, some from out of state; our campaign, by contrast, raised and spent about $90,000, $55,000 to qualify the measure for the ballot (about half of that to pay signature gatherers), and $35,000 for the subsequent campaign. The final yes vote was only 21%, just over a quarter of a million votes.
Measure 23. We proposed a single-payer model, firmly believing that this is the only way to achieve access to secure, affordable health care for all, with support from numerous studies, most recently California?s Health Care Options Project.
Measure 23 was to be financed in three ways. More than a third of the necessary funding would have come from money already being spent by federal, state, and local governments. A progressive income tax of up to 8% of taxable income exempted families with incomes 150% or less of the federal poverty level. Lastly, a progressive employer payroll tax from 3% to 11.5%.
The list of covered services was comprehensive, and included prescription drugs, inpatient and outpatient services, vision, dental, mental health, long-term care, and alternative medicine. The language said that the plan would cover "medically necessary services" "by licensed, certified, or registered health care practitioners." No copays or deductibles.
Oversight and administration would be by a publicly accountable nonprofit Board. Two members were to be elected from each congressional district, and five additional members (including a consumer advocate) would be appointed by the governor. The Board would negotiate compensation with providers.
Major strengths and weaknesses of our campaign. Obviously, our biggest problem was our lack of money to counter the deep pockets of the insurance industry. A poll in October showed us at 36%, the opposition at 39% and 25%
undecided, at which point the opposition, which had not taken us seriously before, began spending serious money. The state?s best-known independent pollster was of the opinion that we would have been able to run a competitive race if we had had as much money as our opponents.
We were also hampered by our lack of major institutional supporters. The AFL-CIO came out in opposition, and the organizations that did endorse us did little to actually help. People who would have benefited greatly from Measure 23 nonetheless failed to support us, in part because of the measure?s complexity and our inability to get our explanations out to them.
Our major strength was our volunteer base. Single-payer universal health care is an issue that brings out idealistic hard-working activists. The HCAO secretary died during the signature-gathering portion of the campaign; while he was in the hospital, he kept a signature sheet on his bed, and demanded all his visitors and medical staff sign it.
The unexpected recession was both a source of support and a problem for us.
On the positive side, more middle-class voters were feeling insecure in their employer-provided health insurance. But everyone was also feeling the economic pinch, and that made it much less likely that a majority would vote for additional taxes. In addition, the recession caused lower 2005 health plan revenue projections, leading to less progressivity in income taxes.
Problems with initiative language. A degree of blame for the defeat of Measure 23 lies with the language itself, which was written by a small language committee with insufficient input from stakeholders, none of whom took our campaign seriously enough at its start to choose to become involved. The initiative represented a broad policy outline, and several details that were left for the plan?s Administrative Board to resolve drew criticism.
Opponents seized on the vague phrase "covers medically necessary services"
"by licensed, certified, or registered health care practitioners" to portray the measure as providing unlimited services. Also, the coverage of alternative medicine offered an easy target for opponents, who claimed repeatedly that the measure would cover aromatherapy, music therapy, and marriage counseling, even hairdressing. Alternative medicine providers themselves generally were nervous about being treated as second-class citizens under the proposed system, and so did not contribute meaningful support.
Physicians and hospitals were nervous about getting adequate reimbursement,
fearing the Administrative Board would negotiate below-cost payment schedules to providers, as current government programs do, and not recognizing the system would have permitted higher reimbursement. There was also some question about whether anti-trust laws would permit group negotiations to take place.
Some physicians, a key stakeholder group, would likely have paid the highest
tax rate under the plan, which also did not make them happy about the measure.
Measure 23 depended on getting federal Medicare and Medicaid waivers. Some
critics said such waivers would be difficult to get, especially from an administration hostile to single payer.
Many voters and physicians were nervous about over-utilization, citing the lack of co-pays and the lack of a spelled-out gatekeeper system. While it costs far more to administer co-pays than they bring in, and they may cause low-income people to defer needed treatment, co-pays may have to be considered from a political standpoint in future legislation.
The cap on the health care tax that the very rich would pay was capped at $25,000 annually. Opponents seized on this number, claiming that many people would pay this much.
State legal counsel advised us that a state could not limit a health-care entitlement simply on the basis of time of residency. Critics claimed the
resulting vague definition of Oregon residency would result in a flood of
out-of-staters and illegal aliens seeking free care.
Campaign issues. As noted above, many of our problems were caused by the simple lack of adequate money and campaign workers.
The refusal of AFL-CIO leadership to become involved in the drafting of the language and its subsequent opposition to the measure scared off endorsement
by many office-holders and lowered our fundraising effectiveness. Labor's bottom line was that they did not want more than 20% of the new funding for the plan to come from income taxes (under the plan this number was about 43%). In Oregon, labor has an electoral machine at least as powerful as the Democratic Party?s, so labor?s opposition was devastating. In addition, as we approached many civic groups, labor usually had preceded us, spreading negativity about the initiative.
Since the campaign was so under-financed, we had to rely on the state Legislative Revenue Office to develop estimates of what individuals and business might pay under Measure 23 . Because the legislature was called to five special sessions to address budget shortfalls, the LRO was too busy to provide these until very late in the campaign.
Under-funding also did not allow us to do any polling. As a result, we did not know what messages would resonate with voters, which demographic groups
to target, etc. We finally went with "Secure, Affordable Health Care for All." The Tribune poll showed us up 8 points with women and down 4 points with men.
Our under-financed Yes on 23 campaign was not able to respond to insurance
industry media blitzes, so most voters only heard one side of the story, focussing on TAXES. About 100 of our ?Max and Maxine? seniors spots and attack ads costing $15,000 aired on extended cable in the last days of the campaign. This may have been a mistake. However, many voters already been swayed by prime-time network TV No on 23 ads by the time these aired.
Supporters and others. Notable endorsers included the Democratic Party of Oregon, Consumers Union (publisher of Consumer Reports), Ecumenical Ministries of Oregon, National Organization for Women (Oregon), a handful of courageous politicians, the Pacific Green Party, PNHP, and, of course, UHCAN. As noted above, we were disappointed by the opposition of much of organized labor, but a handful of individual unions did endorse and support our efforts.
Faith community organizing played little role. It was difficult to get churches involved in a specific piece of legislation. The Catholic Church did not participate, as Measure 23 would have provided funding for reproductive services and assisted suicide and put a nonprofit health insurance organization sponsored by the church out of business.
The Oregon Nurses Association remained neutral. Most of the medical organizations opposed the measure, though a good number of individual physicians endorsed it.
We were not able to do enough outreach to small businesses. The problem is that most small business owners are not joiners and so organizing them was a one-on-one process. J.L. Wilson of the NFIB, who became one of the main faces of the opposition, stated that businesses simply did not want a mandate to participate. (The insurance industry did not appear much in the public debate, but instead allowed business to fight their battle).
The National Association of Retired Federal Workers attacked Measure 23 in emails to its members, even though they would have been exempt under the plan.
How we campaigned.
The HCAO website has been vital in making campaign materials and information available around the state (and country). And the availability of email has been invaluable both in discussing issues among supporters and in organizing.
While HCAO printed materials have generally been professional-looking, they tended to be ?college-ey? in both language and appearance, and hence may not have appealed to some prospective voters. This problem was, of course, exacerbated by the difficult of explaining a complex issue in a few short phrases and soundbites. A summary of the initiative, backed with compelling facts and an expanding list of endorsers, was one of our most important handouts during the signature-gathering phase. During the electoral campaign, we relied on a more user-friendly brochure.
Canvassing and phonebanking efforts did not have enough volunteers to make them effective.
3000 bumperstickers were printed and most distributed. The left side featured "Yes on 23," with "Secure, affordable health care for all" on the right, with white lettering on a green field. In future, we will use blue as a campaign color (as we did for the lawn signs). We are trying to be perceived as non-partisan, and green may reinforce a perception that this is only a "Green" issue.
2000 lawn signs were printed and most distributed. They were handsome,
durable and great for visibility events. 1500 buttons were produced and were
effective in one-to-one outreach.
House meetings did not work well, even after the measure qualified for the ballot. Therefore, we concentrated on making presentations to organizations and leafleting and tabling at events.
There are HCAO chapters in Portland, Corvallis, Eugene, and Ashland. Sheer driving distance made it difficult to organize effectively in rural areas that would have had significantly better health and economic outcomes under Measure 23.
The fundraising firm we put on retainer did a failed mail appeal to grocery store managers and simply relied on our existing donor and contact base thereafter.
A campaign manager and communications director were hired from a failed governor's campaign in June. Their main achievement was improving our press work. There was not enough money to establish a campaign office.
Oregon sends a Voters Pamphlet to every voter. We placed three times the number of Arguments in Favor than the Opposition placed. We even placed the first Argument in Opposition, a satire, that got good publicity and was fun, too. We used our awesome signature gathering machine to set an Oregon record by collecting enough signatures to place eight Arguments in Favor, instead of plunking down $500 for each one.
We were hurt by demographic voting patterns: poor uninsured people tend not to vote. But we tried to capitalize on widespread middle-class worry about health care, and not to portray this as only an effort to expand access to the uninsured. Clearly, this approach was more likely to resonate in the current uncertain economic climate. In a poll the Kennedy School of Government and the Kaiser Foundation conducted of more than a thousand people with health insurance, a full 28 percent said they are very worried they will no longer be able to afford their coverage. Another 22 percent are very worried that their benefits will be cut substantially and 18 percent are very worried they will lose their coverage altogether.
Achievements of the campaign. While other organizations have only complained about the problems of the current health-care system and suggested band-aid solutions, we put a concrete proposal on the table. Our campaign raised the visibility of the single-payer solution in the national media; articles on the campaign appeared in numerous newspapers nationwide, including the Christian Science Monitor, Wall Street Journal, L.A. Times,. etc. I spoke on radio talk shows nationwide putting the concept of a single-payer solution on people's radar screens. Bringing a concrete measure to the table was galvanizing, and inclusion of a funding mechanism forced people to think more critically about funding health care.
The campaign has made many valuable contacts and gained Oregon healthcare activists on-the-job political experience. The No on 23 campaign provides an opposition blueprint for HCAO and other single-payer activists around the country to refer to.
The public debate over the last few months has generated valuable feedback on what Oregonians want in their health-care system. Even some opponents encouraged us to modify Measure 23?s language and to try again. Single-payer universal health care was not taken seriously when we began this campaign. The successes of the Measure 23 campaign mean that many organizations that did not return our calls last time will do so in the future.
Next steps. It is my hope that, in the coming months, key stakeholder groups will work with Health Care for All-Oregon to shape a revised measure, perhaps for 2004. If so, we plan to incorporate members from these stakeholder groups in the our decision making structure. A partial stakeholder list would include: Oregon Nursing Association, Oregon Academy of Family Physicians, progressive business groups, AFL-CIO, The Oregon Association of Hospitals and Health Systems, Portland City Club, public health agencies, Pacific Green Party, the Democratic Party of Oregon, the American Federation of Teachers-Oregon, Oregon Education Association, Oregon School Boards Assn., etc.
A bill with modified language could be submitted again to the Oregon legislature, as we did with HB 3801. While it would probably have little chance of getting out of committee, it might get a hearing and could serve as an organizing tool.
HCAO is also considering other organizing avenues, although the group is split on organizing on issues considered to be incrementalism. It has been suggested, for example, that HCAO could put forward a municipal resolution supporting universal health care in Portland or Eugene, the most liberal cities in the state. SEIU's Oregonians for Health Security has several policy initiatives ongoing, as well as a goal of electing legislators supportive of health care reform. Some HCAO members are working with a coalition seeking to place a campaign finance reform initiative on the 2004 ballot, seeing this as a long-term solution.
Organized labor appears to be focussing on a possible "Health Care for All Children" initiative. Unions have already trimmed members' salaries, services, and choice of providers, and boosted their co-pays and deductibles; the next cost-cutting measure is likely to be to drop workers' dependents from their insurance. In anticipation of this, unions propose a measure that would cover all Oregon children from families under 300% of the federal poverty level, funded by a 2% employer payroll tax.
If we want to get organized labor's support, we will need to find a funding source to lessen the percentage of funding paid by individuals. If we succeed, this would also have the practical effect of stabilizing system funding in lean times. Increasing the employer payroll tax is probably impractical.
Avoid reinventing the wheel. We were able to take some lessons from previous campaigns, such as Massachusetts? Question 5 and California's Prop. 186. I hope health care reform activists can learn from this campaign as well, and encourage them to contact us with questions.
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from Jim Ramsel:
Do You really want to get a health care initiative passed?
If You do then:
1. Leave the initiative alone except remove the income tax cap. The initiative, as written, is not the reason it didn't get passed; HCAO did not have the support of Oregonians and !!if you do your "homework" you will find that no matter what else you do without their support it WONT happen!! Study history to learn how Social Security and Medicare came into being and study our government to learn why programs that redistribute wealth to or for social programs either are under funded or don't become law.
2. Make a plan to educate Oregonians about how Measure 23 would make it possible for EVERYONE to get medically necessary treatment without copayments or deductables and that people in lower income tax brackets would pay less than the do now or nothing if they were at or below 150% of the federal poverty level. Study Chapter 8 of "Profit Fever" by Charles Andrews if you want to re-enforce the idea that this is the proper - the only - path to getting access to health care for all Oregonians.
3. Raise the money to fund your plan. See 4.
4. As per your plan, set an up organization with an organizer and staff at different points throughout Oregon. Talk to Don Bechler to come up with a set of instructions on how to manage house meetings. From this. the placement and the total number or organizers required can be derived once a time schedule has been set. !!Tell the organizers what you want them to do.!! DO NOT LET THEM TURN THIS INTO A POLITICAL CAMPAIGN. As Andrews says "Don't fight in TV
Alley." Isn't it obvious that no matter how hard you try you'll never raise enough money to win there.
ote well that wise council from a member of a Carpenters Union in the AFL-CIO said that the only way to get support from the top brass was to go to the branches and convince the workers to support you and then they would force the brass to support a Measure 23. Sounds like education to me.
Either you educate Oregonians and get a large majority supporting you or you will fail again to get universal health care passed; remember too that *evolution* wont succeed. No matter what anyone tells you, there is no other way. I know; I've done my homework.
jim r
P.S. Visit my websites to see where my knowledge comes from. Most
of the sources are shown on the two reading lists shown there which
represent hundreds and hundreds hours of study.
http://www.efn.org/~ramselj/