September 15, 2020 Blog

State Success Story, Part 2: How Colorado advocates built and used a diverse coalition to give more families access to health care

Guest Authors:
Caitlin Westerson, Policy Director, Colorado Consumer Health Initiative
Erin Miller, Vice President of Health Initiatives, Colorado Children’s Campaign
Allison Neswood, Deputy Director of Strategic Priorities, Colorado Center on Law and Policy

Introduction

A previous blog post, guest written by Colorado advocates Erin Miller, Caitlin Westerson and Allison Neswood, provided a deep dive into the construction of the policy of the new law establishing a Health Insurance Affordability Enterprise (SB215). This law will bring more affordable coverage to Coloradans who buy their own insurance –by repurposing an existing federal fee on insurance companies with a state fee. Equally important is the coalition effort required to get a policy of this size across the finish line and to a governor’s desk for signage. USofCare interviewed these women to hear in their own words how they mobilized over 50 organizations to pass a bill in a sprint effort earlier this year. Embedded within this conversation are key lessons for advocates, stakeholders, and policymakers across the country who aim to advance any policy reform, including expanding health care coverage for people not served by the Affordable Care Act. 

Q: You only had three weeks to accomplish this lofty goal and there was a lot of other stuff happening at the same time with COVID and civil unrest. How were you able to get this done? Were there any critical steps, investments, or organizational tactics that you used, particularly ones that can be replicated again (in Colorado or other states)?

We had actually identified this potential opportunity and workshopped possibilities early on in 2020, which helped quite a bit once COVID hit. Once the legislature took a recess due to the spread of  COVID-19, we took a couple of weeks to gauge interest and figure out priorities among our partners at the table and when it was clear that everyone wanted to try to pass this bill we really got to work. We took advantage of the legislative recess to dig in really, really deep. We called on national experts for technical assistance (multiple times!) and we had weekly calls to discuss everything from policy details to lobbying strategy. We ended up eventually with multiple weekly calls — some lasting until nearly midnight —  because it was a lot to do in such a short amount of time. It’s really amazing that so many people were so committed to this bill. 

Upon reflection, the critical steps that we took were to one, enlist the help of technical assistance–both from state partners like our Division of Insurance and national partners–very early, and talking to them often. Second, we identified our “lines in the sand” and goals for the legislation early on and were very clear with our bill sponsors and lobbyists what those were. It was really important to our group to keep the provision that expanded access to coverage for people without proper documentation and that was risky, but it really paid off in the long run when some legislators saw that as a big win and championed it for us. Finally, we worked to establish open channels of communication and determine decision-making protocols for the coalition — who can be in the google group, who only wants to get email updates, who wants the 11PM text about amendments, etc. This structure allowed us to be nimble and efficient. 

Q: How did your coalition come together? What types of groups did you try to engage? Were there any stakeholder groups or organizations that you intentionally brought in, and why?

Our coalition initially came together rather organically, as many of us typically work together on other health policy issues. In the beginning we kept our coalition meetings small and tight so that we could have an open dialogue without fear of information being shared too widely as we developed strategy. All of the “usual suspects” at the table had been engaged in health equity work and learning around racial equity to some degree — either personally or professionally through their organization. We shared values around using this policy to expand access to coverage to those that have historically faced the greatest structural  barriers to care, and who had been left out of the Affordable Care Act, including people in the family glitch and those without access to the legal immigration system. We worried about the politics of expanding coverage to people without proper documentation, especially during an economic downturn as a result of COVID-19.  But, once we started talking seriously about the expansion of coverage to these groups, we agreed that it was critical to ensure that they were at our table and driving our work.  

We also made the decision to include the state agencies and semi-governmental agencies that would be responsible for implementing the bill. We have close relationships with these agencies and wanted to make sure that whatever we passed could actually be implemented as intended–this proved to be a really helpful tool considering some of our ideas were difficult to figure out. And it speaks to the importance of long-term relationship building for organizations and state agencies. They didn’t laugh us out of the room when we started white boarding proposal.

Once we had a solid policy in place, we started to expand our coalition fairly rapidly. As you may recall, legislatures were moving quickly in the time of COVID, so in a matter of days we had sent out emails to almost everyone we knew that we thought might want to take a position. We intentionally reached out to specific, individual people within those organizations (as opposed to generic outreach) by coalition members that had relationships with those organizations. That strategy resulted in over 50 organizations signing on in support. The key to our success was having a diverse group of stakeholders that could expand in different directions, creating an even more diverse, larger group of supporters.   

Q: How did coalition engagement inform policy development, and vice versa?

There was a coalition of about 10-15 organizations that were really active in the policy development process. They helped make almost every decision there was to make–and that resulted in a really, really strong bill. For example, when someone had a question that no one could answer, we went back to the drawing board to figure it out. It definitely takes more time to do it that way, but in the end we could all speak really proficiently about our policy and we had an answer to almost every question. 

Also as mentioned before, having built relationships ahead of time helped too — we tried to abide by a “no dumb questions” rule — because there really are no dumb questions — if you are wondering about something, there is a great chance that either other folks have the same question, or you have idenfitied a piece of the policy that needs more thought and work. We were fine revisiting and checking early assumptions to build the best possible policy. We must have spent at least 10 hours talking about the funding and implementation timeline alone.

Q: How did you engage communities of color in this process? What dynamics were at play with their policy priorities? 

As we mentioned above, once we were considering using this policy to expand coverage those left out of the Affordable Care Act, including folks in the family glitch and Coloradans without proper documentation, we made it a priority to identify groups that represented them and get them to the table. This meant we had to pause or revisit earlier steps in the process to make sure everyone was up to speed and on the same page, and to make sure the policy was reflecting the community priorities.  For example, one partner explained to us that unless the coverage was basically free it wouldn’t be meaningful to most immigrant communities because they were struggling with access to housing, food insecurity, and job loss at the same time due to COVID. Our response to that was to add a provision of the bill that guarantees the lowest income population gets a 90% actuarial value, $0 premium plan, meaning their out of pocket costs will be very low and the quality of plan will be high. 

Q: Keeping large coalitions together can often get really challenging, especially when compromises have to be considered, or ultimately made. How did you navigate those challenges?

Lots of really tough conversations. Again, we identified our lines in the sand early so we knew what was important to the group and we stuck together–which took a combination of educating one another and pep talks. We knew we’d be stronger if we stuck together and in the end that panned out. And we followed the communication process we outlined. As the final bill came together in the House and compromises were made, we called an emergency meeting of the policy coalition — everyone who had opted into that process got a very-late night text and we got on a Zoom and hashed it out — so we knew what we were willing to accept in the final compromise. 

Q: In campaign efforts, there are often lessons learned and improvements for the future. Is there anything that you would do differently, or conversely, be sure to adopt in future efforts?

One concept we’ve been playing around with as we have continued our meetings to discuss implementation is the idea of “office hours.” Holding times where expert volunteers can be on a Zoom line and folks who have questions that they don’t want to ask in the big group can jump in. We tried to establish a norm around there being no dumb questions, but it can still be hard to ask about some concepts in a big group. As we work to diversify the field of health policy advocates, we’re going to need to create space for shared learning and office hours are one way that we have started doing that. 

Q: If advocates or legislators in another state wanted to replicate SB215, what is the one piece of advice that you would offer?

DO IT NOW.  We weren’t sure we’d get this across the finish line, but people understood the importance of expanding coverage during the pandemic — it’s a great time to push policy solutions that will expand access to coverage without costing state budgets any money and while holding consumers harmless. Some carriers are making record profits and folks now have a greater understanding of the fact that one person’s lack of access to affordable health care in fact jeopardizes the health of all of us.

Conclusion

USofCare is excited to elevate the perspectives of critical advocates, stakeholders and policymakers and share how Caitlin and Erin and their coalition worked to construct and pass SB215 through a collaborative, inclusive coalition effort. We believe that there are lessons to be learned for others, whether on a similar policy or something different entirely:

  1. Center your policy and approach on the people impacted; make sure they are at the table and heard.
  2. Start with shared values, priorities, and objectives for what you want to achieve. Know what your non-negotiables are, and ensure that your coalition and legislative champions are all aligned. 
  3. Build and continue fostering relationships with the technical experts in your state agencies and seek their expertise while crafting your policy.
  4. Have a diverse coalition of stakeholders that can expand in different directions.
  5. Establish an organizational structure that allows members to participate using their strengths, while affording the coalition an ability to be nimble and timely with decision making.
  6. Always be ready: early and consistent education, communication, organization, and relationship building allow you to take advantage of public opinion, changes in the tone and environment, and/or political opportunity.