Could Foundations Have Mounted a Better Defense of the ACA?

By Michael Booth

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 to 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 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, such as immigration and global warming?

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 [that] this was not going to be a cakewalk. But . . .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.

Rob Restuccia, executive director, Community Catalyst—We could have [urged Congress to make] 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.” 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 [that group] said about the ACA were just total lies.

Richard Figueroa, director of prevention and the Affordable Care Act, and Maricela Rodriguez, program manager, the California Endowment—For a thousand-page document, [the law] was generally pretty well written. We would not have gone back to 2008 and said, “Make sure you have a good, functioning website [for the federally facilitated exchange, heathcare.gov].” 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.

Steve McConnell, former country director for US programs, the Atlantic Philanthropies—Atlantic was not a health care foundation when this started—[at least] not in the US. 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 [health reform] didn’t have a home at [this] foundation—it was tacked on. The message is to not avoid doing things that don’t have a home.

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—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 sixty times now? Passing the legislation is now looking like it was the easiest part.

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. 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.

Sara Kay, former head of advocacy and health equity programs, the Atlantic Philanthropies—I’d say we learned smarter storytelling. We learned through research that what [sad personal stories triggered was] 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. But if the messaging had become about “free-riders and poor people,” that would have been a killer on the messaging side.

Richard Figueroa and Maricela Rodriguez—We knew where the foundation could help the most: [with] 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, those partnerships 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.

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

Lori Grubstein, program officer, and Brent Thompson, senior communications officer, the Robert Wood Johnson Foundation—RWJF was supporting coverage efforts since it was founded in the 1970s; folks here were used to the contentiousness of this issue. This foundation was also a very significant player in the health care policy debates of the mid-[19]90s, so we were intimately aware of the partisanship that goes 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.

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 501(c)(4) [“social welfare” organization]. I used to tell people that we just had to tell the truth as a consumer advocate, and [we’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.

Richard Figueroa and Maricela Rodriguez—We were the only foundation in the country that actually filed an amicus brief with the [US] 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. 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.

In fact, our success on the Medicaid side has continued to fuel our interest in [our] #Health4All [campaign], 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!

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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.

Author’s notes: These responses have been edited for length.  For an expanded version of the responses, please visit the Atlas Learning Project’s website.

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

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Center for Evaluation Innovation and Community Catalyst are Atlantic grantees.