FAMILIES USA DAY 2 MORNING PLENARY JANUARY 23, 2015 PAGE 1

Transcription

1 PAGE 1 JENNIFER BEESON: Welcome, everyone. Good morning. Good morning, everyone. Welcome. Welcome, everyone, to day two of Health Action If you were here yesterday you know that this is the 20 th year that we have had Health Action conferences here in Washington and we have a great day lined up for you again today. I m going to make a few announcements and then we ll get started with this plenary. My name is Jen Beeson. I m the Deputy Executive Director of Families USA. I know a lot of you in this room, but if we haven t met yet please introduce yourself to me. I love to get to know the advocates who come to our conferences. I want to make an announcement about the program. In your program it says that lunch starts at 12:30. Well, actually Senator Sherrod Brown from the great state of Ohio will be coming to speak with us at lunch time and he actually starts speaking at 12:30, so we really want you back down in this ballroom at 12:20. And so the program for this morning, this session here goes until 11:00, we have workshops from 11:15 to 12:15, and if you could then make your way from the workshop down to the ballroom we will gather here so that Senator Brown can come and start exactly at 12:30. He has a very tight schedule today, so he is not going to stay for very long. After Senator Brown speaks we ll open up the doors again and people can go out and get lunch, which will be served in a buffet style in the hallways. So, please be in your seats at 12:30. And then one last public service announcement, because I know not everyone is yet in the room this morning, if you are either speaking or moderating at a workshop can you please remind your participants and the attendees in the workshops to be down here at 12:30? This change is reflected in the app if you downloaded the app. Yeah, that he starts speaking at 12:30, so be down here at 12:20. Thank you. So, this session is the future of Medicaid Expansion and the Children s Health Insurance Program, and what we want you to get out of this is the best messaging for promoting and protecting the Medicaid Expansion and extending funding for the Children s Health Insurance Program, which we re just going to keep calling CHIP while we re up here.

2 PAGE 2 Let me take a moment to introduce our two speakers today. On the far left is Bruce Lesley, the President of First Focus, which is a fabulous children s advocacy organization here in D.C. Many of you know Bruce. Bruce has more than 20 years of public policy experience at all levels of government and a demonstrated commitment to making children s lives better. Bruce, we came to know Bruce from his 12 years working on Capitol Hill on healthcare, education, human services, children s issues. Most recently he served as the Senior Health Policy Advisor on the Senate Finance Health Education and Labor, the HELP Committee for Senator Jeff Bingaman. He also worked for U.S. Senator Bob Graham on the Finance Committee. Another fun fact about Bruce is he is from Texas, so occasionally he will throw in Texas references. There you go. To my immediate left is Mike Perry. He is a partner at Perry Undem Communications Strategy and a cofounder of that group. He has conducted policy research for 23 years for nonprofit organizations, foundations, issue organizations, and government agencies. He works on today s most pressing public issues, such as poverty, obesity, and hunger, but he specializes in healthcare research, particularly healthcare reform, Medicaid, and Medicare. And before founding Perry Undem he was a partner at the national polling firm of Lake Research Partners for 16 years, and they have come to our conferences before and talked to us about messaging. Just before I turn it over, Mike is going to speak first and then Bruce is going to speak, they each have slides, and then we re going to take Q and A from the audience. I think there is question cards on your table. We want to get a lot of Q and A, because I think you re going to have interesting questions. Before I turn it over to Mike I just want to make three points about why we re having this discussion about messaging and why we re having it now. So, first of all, despite, as you all know, despite generous federal funding 23 states have not yet taken and implemented the Affordable Care Act s expansion of the Medicaid program for low

3 PAGE 3 income adults in their states, and this has left millions of people with no options for healthcare coverage. Even though the majority of these folks are working, they often either aren t offered employer sponsored insurance or when they are they can t afford it, so it has left millions of people out in the cold. And if you look at the states which have not expanded Medicaid yet you can see in the makeup of those state houses that we have a long term campaign ahead of us in terms of getting to expansion everywhere. It s not a question of if. It s a question of when. Second point about why this is a good time to be having this session is the Children s Health Insurance Program expires on September 30 th of this year, and CHIP has been a wildly popular bipartisan program that covers low income children in the states. It is known by different names in different states. Senator Hatch who now Chairs the Finance Committee has been a longtime champion of children s coverage. It is urgent that Congress act to renew CHIP funding now. Even though funding expires at the end of September, states are making up their budgets right now and they can t wait for that uncertainty of September, so we are urging Congress to act in the next two months to extend CHIP funding. The third quick point I want to make is now that the Senate is in control of Republicans and the House remains in control of Republicans we know that the Medicaid program will be looked at for a possible source of budget cuts. And so what I hope we get from this session is messaging on healthcare coverage that will help us make the connections to the values that all of us share, which is people should be able to see a doctor when they get sick and that we should have access to preventative care and kids should be able to see a doctor. So that is why we re having this session right now. And I m sure some of these issues will come up when we do Q and A. With that I m going to turn it over to you, Mike. MIKE PERRY: Thank you. [Applause] Thanks. I m really excited to be here. I m focusing on the Medicaid Expansion in the remaining states that Jen talked about, and for this talk I m drawing on some research that I did as recently as last week. I was in Texas, Florida, Virginia,

4 PAGE 4 Utah, and North Carolina talking with voters in those states about expanding Medicaid. And this is a project, a joint project between Georgetown Center for Children and Families, Community Catalyst, Center on Budget, and a number of local advocates in those states are helping us think through what this conversation needs to look like in these tough and challenging states. I think the most interesting part of this research is who we were talking with. We were talking with more conservative voters, so these were mostly Republican and Independent voters who are conflicted about the Medicaid program. They don t know much about it at all. They are unhappy about the Affordable Care Act. This is a kind of voter and kind of elected official I think we have got to get better at in talking about Medicaid with this Congress and with the challenges coming forward. So it was fascinating to try and get in their minds about how they think about this program and the value that it brings. And the good news was we got better and better and better at it, and by the time we hit Florida and North Carolina, our last two states, we were by the end of the focus groups having these voters who were completely against accepting the federal money and expanding Medicaid at the beginning of the focus group who were supportive at the back end. So we knew we were doing something right. I don t have this in polished messages for you today, but I thought I would just share with you the things, the breakthroughs that we had, and some of the challenges we faced. So, the-- It s weird looking at myself. There we go. So, the first thing that I noticed, I have been working on Medicaid Expansion messaging for about two years now, and I noticed that the messaging is different in these remaining states. In Utah, for example, you re not talking about expanding Medicaid, you re talking about the Governor s Healthy Utah plan. That s what you re talking about in Utah. So, this conversation is morphing and changing and evolving. Tennessee now with their plan, it s changing really rapidly. So, from a messaging point of view we really need to be on our toes and fluid.

5 PAGE 5 Also something that is emerging that wasn t there before are these waiver ideas. So these plans include premiums and copayments and healthy behaviors in these states, and so how do we talk about those things? I know that we try not to have those kind of conversations when it comes to Medicaid. We try to cut them short. We don t really want to go down this pathway, but in these focus groups we did. We wanted to see how deeply these feelings were around waiver ideas. The messengers are different. It s really hard in these states to find trustworthy messengers. There is a lot of heavy cynicism and skepticism going on. So the conversation is different. The messages are different. So that is the first sort of thing that struck me about these states. So, where do they start the conversation? And I think these findings have application to some of the larger challenges facing Medicaid right now. They re not paying attention to Medicaid. So, although we care so much about this program, these voters in every single state feel that this issue is not personally relevant, that they re not connected to Medicaid. Ironically, many of them were. We all know that Medicaid touches most people s lives, and so they could talk about a grandparent, a parent, a child they know, so they were connected. But it was odd, they just didn t see that connection, they didn t feel connected to this program. That is the first thing that we noticed. Even though the debate in some of these states has been so intense, it was striking that in every single one of these states they really were not aware that their state had made a decision around Medicaid, had turned down funding, that there was this ongoing debate about whether to accept the funding or not. So it just hasn t penetrated to voters. In every state except for Utah where the Governor has really embraced the Healthy Utah plan that we went to they were unsure of their Governor s position on this issue, so they didn t know. Even in Texas, they assumed the Governor would have been against it, but they didn t know for sure. And they were unhappy about the Affordable Care Act. I need to talk about that for a minute, because as we talk about Medicaid and as we talk about CHIP I know there is a desire to

6 PAGE 6 keep these conversations separate from feelings and decisions around the Affordable Care Act, but that is going to be hard to do. In voters minds they conflate a lot of these issues right now. They don t know much about the Affordable Care Act. They don t know where it begins and ends. And so everything they are frustrated with in healthcare right now they re attaching to the Affordable Care Act. So know that it s going to be hard to sort of keep that out of the conversation. It kept popping up as we were talking about Medicaid. This group is really wary of federal government, of politicians right now, just very cynical, very skeptical. Any time that in our messaging we have referenced federal government, the money is coming from the federal government to pay for this expansion, we got in trouble. You know, Why is Washington involved in Texas? I don t understand why the federal government has to be involved in our state and tell us what to do. So we got into trouble. They are uninformed and conflicted about Medicaid, so let me spend a minute there, and this is consistent with all the research that I ve done with Medicaid over the years. The public does not understand Medicaid. We still need to educate. It s part of our jobs is to educate people about Medicaid. They still don t seem to understand it. What they think about the program is that they think that, many of these more conservative voters view it as a handout. They think there is a lot of abuse in the program, not just by the beneficiaries but by physicians and others, so they talk about abuse a lot in these focus groups. But they think it s an important program and polling has shown that. About 70 or more percent of the public thinks this is an important program. They don t want to cut it. So there is this weird thing where they have these negative feelings about the program and around abuse, that some people are getting help from Medicaid who shouldn t, and yet they think it s a really important program. So these conflicted feelings are present whenever you talk about Medicaid.

7 PAGE 7 New finding for me, someone who has worked on this issue, is that when I was in states like Texas and Florida they had no idea how low their eligibility levels were. I think that was really important for us to educate about how low they were. So, they assumed that if someone lost a job and became unemployed they got Medicaid. I think I find that assumption in just about every state I go to. They kept on asking, Well, why isn t-- Why aren t these people getting Medicaid? When we talked about the coverage gap, Why aren t they getting Medicaid? I don t understand. They think their Medicaid programs are way more generous in a number of these states than they really are. It was eye-opening to them, for example, that you would be a childless adult and not qualify at all for Medicaid. So it was a good teaching moment for us and a good thing to raise. And then they haven t heard about the coverage gap. I know that in a lot of the messaging work I m doing that a number of us are really excited to talk about this as a coverage gap, but know that it s really hard to define the coverage gap. They haven t heard of it and it takes a while to explain it. I ll talk more about that in a minute. So, framing this decision. So, what is the decision? How do you talk to voters about what the decision is that their state is making around this issue? In the early work that we did we tested expanding Medicaid versus covering more uninsured, so accepting federal money to cover more uninsured in our state versus accepting federal money to expand the Medicaid program. We found about a 10% differential in favor of covering more uninsured. So our initial advice was even though the opposition may be talking about this as expanding Medicaid that s not what you say. You need to talk about this more broadly, that this is about accepting or turning down money that has already been allocated to cover more uninsured. More recently in these states that I have gone into I have become myself conflicted about this framing, because when we started talking about covering more uninsured people we got a lot of questions about who are these people, why aren t they working, I don t understand. There was a sense that they were higher income than they really were. There were just-- These kind of

8 PAGE 8 voters really scrutinize who would benefit from this program, and so it wasn t really working as well. We started then framing this as this is about closing the coverage gap, this is a decision the state can make about closing the coverage gap. The problem there is they don t know what the coverage gap is. They think it is people who earn too much to make Medicaid, so anyone who is uninsured above the Medicaid level. So if you don t educate them that is who they think it is. The good news is they are very sympathetic to those kind of families, so it s a little bit of false pretenses. They like this framing, because they don t fully understand it. They think they know who it is. They think it could be them if they lost their insurance. So it does well, but mainly it does well because they don t really understand what the coverage gap is. It takes me a good five minutes to explain the coverage gap in those focus groups. So, if we use it right up front just know that there is misperceptions about it. Lastly, we started moving to calling this a state plan. So we talked about Healthy Florida and Healthy North Carolina and Healthy Virginia. There is a plan in our state to cover more uninsured state residents. That had some drawbacks. A lot of people are not feeling good about their state s ability to do health plans effectively, to manage this effectively. Ironically, in Florida by the end of the focus group they said, Well, why don t we just expand Medicaid? I don t know, Mike, why you re talking about Healthy Florida. So anyway, that s why there is a big question mark. I don t know what to tell you, honestly, about how to frame this conversation. I want to give you a sense that we really, this is the kind of place we are in right now. The world has changed around Medicaid nationally and in states and this is the kind of challenges we re facing. The messaging may be different by states on this issue. So, some of the obstacles. I want to give you a sense of some of the issues we faced. So, any time, again, I talked about federal government was a problem. Explaining where the money was coming from. These voters want to know how is this being paid for. You have to answer them. I am becoming anti-message the more I do this work in this environment. They really want facts.

9 PAGE 9 They really want unbiased information. They really want you to be straight with them. And so more and more I am leaving behind more values based messaging and just giving them more facts about the program and that seemed to win the day. They really had a pragmatic point of view. When I tried to explain the money the way I explained it was problematic. I talked about the 100% federal government share for the first two years, and then after that a 90% share. So there was a lot of objections around this 100%. That sounds like a handout. The federal government paying 100% of anything, it sounds like a handout. I don t like that. Don t they have better uses for their money? Why are they giving 100%? They got stuck on the 10% share. That was our biggest message barrier, to tell you the truth. That was the attack that we had to beat back. They got hung up on this 10%. That s a lot of money. Budgets are tight. We would have to cut education. So the 10% ended up being the message we had to, the issue we had to address. They believe their taxes are going up. Bottom line, no matter what you say, they really believe their taxes are going to go up to pay for this program, so we had to address that. They are unaware that people fall into the coverage gap. So they don t know what the problem is. So we re telling them about this decision facing the state and they don t know what the problem is. They don t know that there are people caught in the gap. So we always have to, although it s challenging, we have to define the coverage gap. And there are few trusted messengers. We got pushed back on physicians and nurses and the tried and true messengers that typically work on this issue. In these states we got pushback. They thought they would have an agenda. They thought, Okay, they re going to be for this, of course, because they re going to get paid more. Hospitals, as we know, have been very vocal on this issue. I thought they would be a trusted messenger in these states. No, hospitals have an agenda, they want to make money on this. Hospitals are not trusted. Their Governor, Governor only worked in Utah. It didn t work in any of the other states we were in. In Virginia, he s not even Virginian, he s not our Governor, no, no, no. So we got a lot of pushback on who to use.

10 PAGE 10 The most neutral sources were the best. So we talked about researchers, economists, sort of doing cost benefit analysis. That kind of data was trusted. Other messengers weren t. So these are tough, tough, tough states. But there are some opportunities too. They want to help working families, so it really matters how we define who this population is. They can be educated about the coverage gap. We talked about how the money has already been earmarked, set aside. That ultimately was the argument that won the day. We were torn about whether we should talk about the Affordable Care Act in these focus groups or not. We decided we had to. They had to know where the money was coming from. We had to say that the money had been set aside by the Affordable Care Act for this purpose, and if you don t use it they re going to keep the money. So that s how we had to talk about it. They re going to keep your money. It doesn t work to say it s going to go to other states. We found that that worked only in one state. In the other states they re going to keep your money. We talked about a hospital fee. This is being talked about in Tennessee and some other states. The hospitals are going to pay for that 10%. That really worked. That worked well. We talked about economists saying that this plan will be cost neutral to the state s budget. That worked really well. In Utah it really mattered that the Governor was behind the plan. They like the Governor. That really helped. It did not help to attach the Governor to a plan in other states. Lastly, in these states we do have to talk about the economic benefits to the state, job creation. We have to be very specific about that. It s not a top tier message, but it does well. So let me sort of last big topic I want to talk about before I end is waiver ideas, again uncomfortable conversations for all of us. The main thing here is personal responsibility. These voters want personal responsibility in Medicaid. We should be able to talk about personal responsibility. We should own that. These are individuals who are being personally responsible by signing up for the program.

11 PAGE 11 We tested a number of things. The main thing that you need to know is we were able to push back on just about every one of these ideas. So the idea of charging premiums to beneficiaries, we talked about what if this means they don t sign up in the first place, they can t afford a $30 dollar premium? That helped us push back on that. On copays, we said, What if this means someone puts off getting care when they re sick because they can t afford the copay? They re like, You re right, Mike. You re right. Let s make it only five or 10 dollars. We talked about healthy behaviors. That was probably our biggest win. Very much behind incentives and discounts as opposed to penalties, so it was easy to win. Work requirements were tough. How we did well on that is talking about the complexity of monitoring work requirements. So it s not the kind of argument we would want to use, but what worked with this kind of conservative mindset was the bureaucracy of monitoring is more red tape and more government and I don t want that, so we pushed back. So, let me end by saying what worked. So what worked in the end, what we are-- it would have been nice if I was on that slide, huh-- so what worked in the end is to really define who we re talking about. These are working families who need the security of health insurance, so working families. It was important to give the sample income amounts that we re talking about for the people in the coverage gap. It was a new finding, talking about the industries that they come from. So these are people with jobs in construction, landscaping, childcare, tourism. That really mattered. It really sort of personified who we are talking about. It got rid of some of their negative impressions. Defining the coverage gap, using researchers and economists as messengers, talking about the plan being cost neutral. A really good word if we can say it, cost neutral really did really well. Talking about the state being able to opt out at any time, that mattered in these states. Taking about this as a pilot program was effective. We had to say that the money was being set aside by the Affordable Care Act. And then we also had to say if we do not accept this money the federal government will keep our taxpayer dollars.

12 PAGE 12 We also to remind them if we do nothing, if we don t take this money these individuals will still go to the ER sicker and will cost us all more money. So I will stop there with those insights and hand it over to Bruce. Thank you. [Applause] BRUCE LESLEY: Thank you very much. I really appreciate being invited here today to talk to you all and just do a quick word about Families USA. During my time on Capitol Hill we faced some good fights and some bad fights. For example, there was twice, on two occasions when I was working in the Senate there were proposals to block grant the Medicaid program, and Families USA was like the leading group to help. And there was a point where we had 45 Democratic Senators, 55 Republican Senators. It had passed the House. It came over to the Senate. And there was actually pushback in the community to say, Yeah, maybe you shouldn t do an amendment, we shouldn t push an amendment to strike the block grant. But it was, I had a great conversation with Ron Pollack about that and Jen and folks at Families USA and we decided to go for it. And because if you left it in the budget then it ends up being sort of a self-fulfilling thing. So there is a lot of skepticism that we would win, but through the work of Families USA, all the people in this room we won. We won on a vote and so we had beaten back block grants. And then the other thing is things like the ACA and the CHIP expansion that happened in 1997 and Families USA played an enormous role there. And so I just want to thank you all and Families USA itself, but all of you for all the work on those, the progress we have made over time. So, sometimes as we re playing defense we have got to remember that we have actually made some great progress.

13 PAGE 13 And so that leads into what I want to talk about. So, first, I m going to talk about three things, one is I m going to build a little bit on Mike s presentation talking about how do we sell the Medicaid Expansion in states. I m going to talk a little bit, so he talked about sort of the offense, I m actually going to talk about the defense, which is we are undoubtedly going to see a budget reconciliation process in Washington this year and based on past indications we would expect that there are going to be efforts to cut Medicaid pretty dramatically, so I want to talk a little bit about that and some of the work we have done on polling that may be helpful. And then second, talking about CHIP, and we re trying to get CHIP extended and reauthorized and some of the work that we have been doing jointly with Families USA on that, and some of the messaging we have been doing. We have been doing joint press releases and op-eds and phone calls with editorial boards, and some of what we re saying jointly to people across the country about that effort. And then the last one I want to talk about legal immigrant children and an effort that we think will happen to try to roll back coverage. So, if you like numbers I m going to put a lot of numbers on the screen. I m not going to talk about them this much, but you can look at them. For those of you who don t like numbers, just ignore them. Just know that really what I m saying is there is support for a lot of what we re saying, and then you can focus on sort of the messages. So, with that said, if I can go back, there we go. Alright, so the first thing is the issue of Medicaid. And so we use a Republican firm actually to do these polls and we ask people do you think we should reduce the federal deficit? And so of those folks, the people who said, Yes, we should cut spending at the federal level to reduce the deficit then we asked the question, Do you think Medicaid, we should cut Medicaid to help balance the budget? So these were people already inclined to say we need to cut spending. And what you can see is Medicaid did very well. People said, Well, not Medicaid. And then you can see by a 73/27 margin people said, You shouldn t touch Medicaid. And I will note that

14 PAGE 14 Medicare was at 74. So, Medicaid did about as well as Medicare, which was really great, and you can see how the Children s Health Insurance Program it was 67/29 as well, so people said absolutely oppose cutting Medicaid and CHIP. The AV numbers are another poll and you can see basically about 70% of voters said in that poll as well, and that s American Viewpoint poll, they said, Don t cut Medicaid or CHIP. And it s bipartisan, Democrats, Republicans, and tri-partisan, Independents, all saying, Don t cut these programs. So, we did some work with Drew Weston and he does dial testing, and he tested certain messages. And so I m going to put up some of these and we ll focus on a few. So, what you can see here, I don t know if people can read all those, but I will focus sort of on the first one. And this is something that Families USA has said for years, which is when you talk about Medicaid it s really important to put the people we are talking about in picture, otherwise it s just a program. So, talking about, and talking about all the different types of people in the program. So if you talk about kids and adults and senior citizens and people with disabilities that s the key. And you can see on the dials. And so if you get over, if people turn the dial up above 60% they really like that message, and you can see the mean test on that message about Medicaid pays for immunizations for kids, cancer screenings, treatment for adults, nursing home care for seniors, people with disabilities. If that is what we want to cut it s time to rethink our priorities and people really resonated overwhelmingly with those kinds of messages. And you can see kind of similar themes across the board, so kind of different takes on it. But the key point here is to really put in people s minds who we re talking about, who is served by these programs, and if they get that they support it. And you can see some similar things here. And also I would note that people are still very populist about things, and so I think the big applause line in the President s speech the other

15 PAGE 15 night was if you think you can live on $15,000 dollars a year then try it. The same kind of thing is if you really put people and kind of pit the people served by Medicaid versus other insurance companies, other kinds of things it does, that also resonates very well. So, the good thing is as we go into this debate I think we have some messages and some things that we can really use in our toolkit to fight those kind of cuts and efforts. So with that I m going to transition quickly to CHIP. And so a couple things I think are important to think about and say about CHIP is if you looked at the polling on CHIP a few years ago when we had the big fight about reauthorizing CHIP and there was the vetoes the American public really knew about the program a lot, and so there was very little I don t knows, but over time one of the things that has happened is as we have had huge conversation about the Affordable Care Act and other things in many states people talk about the CHIP under different names there is actually a good chunk of people who don t know what Children s Health Insurance Program is, so one thing is to really educate people. So one of the key things is people think government doesn t work, so if you talk about things, CHIP I think a key message is that it actually has worked in a very, it s a bipartisan program that is very successful in tandem with Medicaid. So, CHIP and Medicaid together have resulted in the, since the enactment of CHIP have cut the uninsured rate for kids by more than half. And when you talk about that people go, Well that s great. That s what we want to hear about a government program is that it actually works. Now it covers over eight million children across the country and you can see I just put that up for people s kind of knowledge that it really has been remarkable, because the uninsured rate in a lot of states was well over 20% and now the worst state in the country the uninsured rate is 13, 14%. But states like Arkansas have an uninsured rate for kids at six percent, right? And so you tell people that, they can t even believe it that there are Southern states with a very low uninsured rate for kids, and it s attributable to CHIP and Medicaid.

16 PAGE 16 So, Jen talked a little bit about this, so I won t talk about this too much, but I just want to point out the one thing about CHIP is it s a little complicated this year, because it s kind of a trificated system. So, one thing that is in CHIP that is very important in the CHIP Extension was express line eligibility, and it allows simplified, states to take up simplified eligibility. That expires at the end of March, so we need that to be extended really early. CHIP expires at the end of September. However, for states to know what their budgets are to plan we are really pushing, there is a-- the message we re asking for is a four year extension and to do it by the end of the first quarter, so by March. And so we re working on that and trying to get both of those things extended as soon as possible in this first quarter, so there is some urgency around this. And then last, the maintenance of effort is a very important thing, so it prohibits states from detracting and cutting Medicaid and CHIP eligibility. So, why CHIP? Just one quick point is the ACA was purposely set to sit on top of Medicaid and CHIP, so if CHIP goes away the problem that happens is that it s a program that is set up for a little bit higher income families, and so if you move kids into the Affordable Care Act their costs go up, their benefits are lower. And so that is why we are jointly, it was purposely set up that way and we want to keep CHIP going. We would love to see the ACA extended in a way and improved so that CHIP kids would not be left worse off if it went away, but what this chart really shows is that the out of pocket for kids would go up dramatically if CHIP were to go away. So, how is support for CHIP? So, you ll see that initially people do favor it, so if you ask people, Do you think CHIP should be extended? it s a 51 to 15 support level, but you can see a third of Americans say, I don t really know much about it. And so you can see there is over time people have lost track of what it is. But if you explain it in a very simple way, which the poll did, you can see support jumps, skyrockets dramatically. So you sort of, it s a reminder to people, what we found in the focus groups on it is people go, Oh yeah, yeah, yeah, I know that program. Yes. Yes, I love our kids in Arkansas. I love Badger Care. And so if you familiarize people they

17 PAGE 17 immediately go, Yeah, yeah, yeah, yeah. I like it. And so then it jumps to 74/14. So that is the level of support we have and it s across the board. And I ll show you that. Democrats, Republicans, Independents, you can see strong support even with the Republicans, it s over a three to one margin support for the program. And we also asked people, Are you a Tea Party sympathizer or supporter? and even they, 66/18, which we thought was amazing. And we also asked them the question of, they are the ones who really are talking about balancing the budget and cutting federal spending, we asked them in the question about, Do you think you should cut Medicaid and CHIP? and amazing numbers from Tea Party folks about, No, that s not what we re talking about. So, we have even Tea Party people saying, Don t cut spending. So, there is often worry in this organization, we are inclined not to speak to them about some things, and I would say on this issue their voters are actually inclined to say, No, you don t cut Medicaid and CHIP. I would also point out something that it cuts across gender, age, and race lines, but one thing I want to point out that I think is just interesting, so just something, is it s not, on so many issues that we poll on there is definitely a gender gap, women are more supportive on health issues than men, but what is really interesting here is that for young people there is sort of a different take. The gender gap is actually among older Republican men, white men are actually the one demographic that is sort of a little bit of a problem, like it s more closer to 50/50, but if you look at younger men they poll just as well, and even in the two polls we have done on this slightly better than even younger women. So, there is something going on here in this new generation that gives me some hope that we ll have a lot of-- Men are coming around. [Applause] And I say this now because later on I m going to tell you something bad about men, and so it s kind of embarrassing.

18 PAGE 18 So, a couple of polling conclusions I just want to point out is the biggest challenge for CHIP is not that there is opposition to it, it s that people don t know about it, so educating people about it is very important. It s one of the reasons why we have been working really closely with Families USA on op-eds and getting editorials and getting the information out in the public, social media, etc. The other thing is there is not blowback on CHIP over the debate over the Affordable Care Act. So, we were really worried that Republicans who just so have things with Obamacare may put a pox on everything, and that s not true. They see a difference. They don t necessarily put CHIP in the same boat. Even if they are opposed to Obamacare they still are inclined to support CHIP. And a good message for Republicans is to really focus on that it s bipartisan, that it s state run, and it s successful. And so the message that we got from American Viewpoint, which is a Republican firm, was they thought sort of the overriding message was this issue of bipartisan children s healthcare that works for working families. And this gets back to the point again of really focusing on the population that is served and what it does for them. So, it provides immunizations and cancer treatment and things like that, and people are like, Yes, no child should go without those things. Some dos and don ts. I won t walk through all of these, but definitely the educating issue, focusing on the bipartisan nature of the program. Also the phrase economic lifeline for families and their children really resonated with people. In the dials people really turned up the dials on that message, which was interesting, so there is still a lot of economic uncertainty in the public and that worked really well. Testimonials so that people know real stories, narrative works. And then last if we re really trying to gin up support the groups that were the best, of course, are moms, younger women, and Democrats are key coalition partners.

19 PAGE 19 Things not to do is don t compare it to Medicare. There was something to say we should do for kids in CHIP what is done for seniors in Medicare. It works with a lot of demographics, but interestingly enough Republican men go, No, I don t think so, because they have that sort of family bubble perception about kids, that is a parent s responsibility, Medicare is a whole different thing, so don t go there. So it s not worth it. We have huge support. We don t need to go down that path, particularly if it alienates a group, so don t make comparisons like that. And I think that is the most of what I want to talk about. The other thing is in psychology people are, if you have people play a game where they can get money or possibly lose money they will take, always take the path of not, of being loss averse, so one of the really best messages we found in the dials was this issue of don t gamble with someone s health, and so that has been one of the most powerful messages is to, when we talk about CHIP it s a good program, it works, it s bipartisan; don t gamble with children s health. People turned up the dials widely. And as I told you, if it s over 60 people really support it. And again that is not a support level, that s how high they turn up the numbers. And you can see the average margin there is 80, so people incredibly turn up the dials on that message. People are like, No, we shouldn t do that. So, that is a really strong message. And the last thing I want to talk about was the issue about immigrant children. So, both Medicaid and the Children s Health Insurance Program provide states the option of covering legal immigrant children and pregnant women, and some states have taken the option, some have not, but there is unlike, there is highly likely an effort going to be to repeal that in this Congress. And so one of the things that we have taken note of is as progressives we tend to think that if argue, if we just come up with another argument. So I worked on the first ICHIA bill back in 1997 and over time we just kept adding arguments and so we would say, Well, and then there is this point and then there is this point. So we had a 12 page fact sheet that we would take up to the hill saying, Here is the 700 reasons why you should support the Immigrant Children s Health Insurance Program, Improvement Act.

20 PAGE 20 And what we found in this poll is we actually did a side by side where we told people that just the very simple fact of no child should have to wait five years for healthcare coverage. A kid with cancer, a kid in need of eyeglasses, they can t wait five years. You shouldn t put a five year waiting period on them. Huge support for that. So you see 67/19, people, you have Rush Limbaugh on stuff like, Rush Limbaugh voters. So you don t need to get into all these other issues. So then we tested what about adding the ideas? So we then said, No child should wait five years. By the way, the other great argument on this is asking pregnant women to wait five years, it s kind of stupid, right? It just makes no sense at all. But if you say, No child should wait five years to get healthcare coverage and their parents pay taxes it was fascinating to see what happens. And we did some work with NILC, the National Immigration Law Center on this, and what was really interesting is women and Democrats, so again this is going to be a this is women are smarter than men point here, is that argument, the support level actually went up, so it does work with women. But for men you saw a 20 point drop in some places. And the issue is as you add in another frame, you re adding in the frame of taxes, then they go, Whoa, taxes, and they turn around. So, I think the best message here is to stick to the frame of nobody should wait five years, kids should not wait five years for healthcare, and this point of and asking pregnant women to wait five years is stupid and nonsensical is actually our best message and it puts then the burden of saying why you should impose a five year waiting period on the opposition. And that is actually a hard thing for them to say, because then they have to get into demeaning and arguments like that that the American people are like, What? What is that? Why would you do that? So, simplify is actually the best point here. So, with that, thank you. [Applause]

21 PAGE 21 JENNIFER BEESON: So we want to take your questions and there should be cards on your table. Hopefully you re already writing some of them out, and we ll send a couple of people around to pick them up. In the meantime let me turn to you two and ask you a question. In terms of Congress I wrote down a really simple message around CHIP. Four year extension. Do it before the end of March. That s the message for members of Congress before the end of March. For Mike, I think your messaging is a little more complicated, but the main takeaway I got from you was stick to the facts. What if any messaging testing did you do around lawmakers or do you think these same kinds of messages work? MIKE PERRY: Go ahead, Bruce. BRUCE LESLEY: Oh, so on Congress I think that does work. I think that a very simple message. I think also it s important to note that for a lot of these members they were not around for the reauthorization of CHIP, nor were they even around for the passage of the Affordable Care Act. So, I think there is a little bit of educating them on what Medicaid and CHIP are and pointing out to them that they re bipartisan, because for many of them all they have ever done is vote to repeal Obamacare, so we walk into offices all the time where we say, Hey, by the way your boss voted in the past, we ll talk to the staff and say, Your boss voted in the past to support the Children s Health Insurance Program, and they re like, What? Because they have only worked for their boss, they have only voted no, no, voted to repeal, so they are like, Oh, we had no idea. So I think it s the very simple message of, Let s pass it, extend it, but kind of giving them a little bit of why and the success of it. MIKE PERRY: I would just add in the past I have done focus groups with hill staff members and with state legislators about both CHIP and Medicaid, and I concur with Bruce. Don t think they know a lot about these programs or they re that different from voters, honestly. They really

22 PAGE 22 need a lot of education around CHIP, around Medicaid, so I think that is definitely a place to start, what these programs are, who is in these programs, and why they matter. JENNIFER BEESON: Okay, I have a couple questions here for Mike. When you tested messengers did you test community leaders like ministers or other faith based leaders as trusted messengers? Was that one group? MIKE PERRY: That is a great question. I was afraid someone was going to ask that question. We think they would be a good messenger, particularly in some of the states we went to. We didn t. We tried to get from them who they would trust. We did try and go down a level. We tested Mayors in a number of the cities we went to. We talked to in Utah I think it was a Subaru dealership guy who had been outspoken on this issue. So we did try a range of these and they all had pros and cons. Unfortunately, I hate to report that most voters don t know who their Mayors are, so that didn t help us. So we didn t. We were just talking. As we do more research on this we think we want to bring in faith leaders. We think they are a great messenger to test on this. But we didn t have luck with small business owners. We didn t have luck with Chambers of Commerce. We didn t have luck with Mayors and sort of lower level political leaders. JENNIFER BEESON: Okay. And the best messengers you found were sort of neutral sources, researchers, things like that. MIKE PERRY: Exactly. JENNIFER BEESON: So in advocating for Medicaid expansion how do red state conservatives respond to messaging about the need to keep funds in order to sustain rural hospitals that are at risk of closing?

23 PAGE 23 MIKE PERRY: Great question. We talked about rural hospitals. So, we asked in these states, we knew in North Carolina, for example, there had been hospital closings, that it had been an issue, and so we talked about in North Carolina had you heard that hospitals had been closing, do you know this is an issue for hospitals. They were not aware of that. What they kept on talking about is the big health systems in Charlotte and it was sort of unbelievable to them that a hospital could actually fail. What they also said, the pushback we got is, Well, if a hospital fails it s because of other kinds of things, bad management. It s not because of this. So we pushed quite hard on it. I think if we had gone to a rural area I think that we would have had more luck, but we didn t have luck talking about hospitals closing their door, and even when we talked about rural hospitals who communities depend on we got pushback on that. It just was not believable. They think they re rich and have a lot of money and if they close it s because of mismanagement. I still think talking about hospitals closing their doors is good, but hospitals as a messenger, local hospitals as a messenger was proven problematic among these kind of voters. BRUCE LESLEY: To the public, right? MARK PERRY: Yes, to conservative voters who we were talking to in those states. BRUCE LESLEY: And I would say, and I think if I could add to that, I think that to a hill staffer that is kind of a different, because they re going to respond-- In lots of rural areas of course those are the biggest employers, and so that will freak out politicians and stuff. But different messenger for the public. JENNIFER BEESON: Different message for different people. So the hospital case may be persuasive for the actual lawmaker, if not the public. I have a question here for Bruce. I misread it at first. I thought it was for Brad. I was like, Oh man, Brad isn t even up here. [Laughter] For

24 PAGE 24 states that currently haven t picked up the ICHIA option, this is the Immigrant Children s Health Improvement Act, the option to cover immigrant kids and get rid of that five year bar, do you think there is a place to push for that during our CHIP funding advocacy? Let me rephrase. Where are we on ICHIA? BRUCE LESLEY: So, I could kick it to Brad if he wants to do it. JENNIFER BEESON: You want Brad to answer that one? BRUCE LESLEY: No. About half the states have taken up the option, and which has been great, and we certainly would love to see other states do it. I mean there is important states that have not, like Florida. So, I think to continue to push on that is, and the same message works. We saw advocates almost get across the finish line in some states with these messages of allowing kids to wait five years. That is not-- That s terrible. And it does resonate. So I think yes, I think as at the state level that is something to continue to push. And then at the federal level it s more of a defensive. We want to keep the option in place. We don t want that shut off. Because there is two things they could do. They could repeal it for everyone or the other option they could do is say, Okay, we re going to freeze everything in place. States that have it can keep it, but no one else can ever take up the option. And we don t want a scenario where some legal immigrants some places can get it and others, they can t ever get it. So I think kind of a defense/offense agenda. JENNIFER BEESON: I have a question here that is about emergency room use. Expanding Medicaid coverage, the theory goes, reduces emergency room use. Legislators and maybe the public may not know that much about Medicaid expansion, but they know that in Oregon emergency room use actually went up with expansion. Now I think there is a footnote to that which is over time that goes down, but did either one of you want to talk about that?