screeria -- nigeria. -r sherrod

brown who talks about the affordable care act. this is an hour and 15 minutes. 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 c.h.i.p. let me take a moment to introduce our two speakers. on the far left is bruce leslie, 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 health care education, human services, children's issues. most recently he served as the senior health policy adviser on the senate finance health, education, and labor, the h.e.l.p. 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's from texas so occasionally he will throw in texas references. there you go. to my immediate left is mike perry. he's a partner at perry undum communication strategy and a co-founder of that group. he's 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 health care research, particularly health care reform, medicaid and medicare, and before founding perry undum he was a partner at 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 & a from the audience. i think there's question cards on your table. we want to get a lot of q & a because i think you will 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 messages 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-income adults in their states. and this has left millions of people with no options for health care 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's left millions of people out in the cold. if you look at the states which have not expanded medicaid yet, you can see in the makeup of the state house that is 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 30th of this year, and c.h.i.p has been a wildly popular bipartisan program that covers low-income children in the states. it's known by different names in

different states. senator hatch who chairs the finance committee has been a long-time champion of children's coverage. it's urgent that congress act to renew c.h.i.p. 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 c.h.i.p. 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 health care 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's why we're having this session right now, and i'm sure some of these issues will come up when we do q & a. with that i'm going to turn it over to you, mike. >> 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, 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 of budget and a number of local advocates in those states. they 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. these were mostly republican and independent voters who are conflicted about the medicaid program. they don't know much about it at all. they're unhappy about the affordable care act. this is a kind of voter and kind of elected official. i think we've got to get better at talking with medicaid with this congress and with the challenges coming forward. it's fascinating to try to 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 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 but i thought i'd share with you the breakthroughs we had and some of the challenges we faced.

it's weird looking at myself changing. there we go. all right. so the first thing that i noticed, i have been working on medicaid expansion messaging for about two years now and i mtsed that the messaging is different in the 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 evolving. tennessee now with their plan is changing really rapidly. so from a messaging point of view, we really need to be on our toes and fluid. also something that is emerging that wasn't there before are these waiver ideas. so these plans include premiums and co-payments 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 kferthsconversations when we come to medicaid. we don't really want to go down the pathway but in the focus groups we did. we wanted to see how deeply these feelings were around waiver ideas. the messengers are different. it's hard to find trustworthy messengers. there's a lot of heavy cynicism and skepticism going on. so the conversation is different, the messages are different. that's the first 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 challenging 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 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's 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. 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 c.h.i.p., i know there's a desire to keep that's conversations separate from feelings and decisions around the affordable care act but that's 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 so everything they're frustrated with in health care right now, they're attaching to the affordable care act. know it's going to be hard to 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. anytime in our messaging we referenced the 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're uninformed and conflicted about medicaid. so let me spend a minute there, and this is consistent with all the research i have 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's 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. they -- but they think it's an important program and polling has shown that. 70% or more of the public think it's an important program, they don't want to cut it, so it's a weird thing where they have these negative feelings about the program around abuse, that some people are getting help that shunt and yet they they it's an important program. so these conflicted feelings are present whenever you talk about medicaid. new finding for me somebody who has worked on this issue, is when i was in states like texas and florida, they had no idea how low their eligibility levels were. i think that's really important for to us 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 aren't these people getting medicaid? we talked about the coverage gap. why aren't they getting medicaid i don't understand. they think the medicaid programs are way more generous than they are. it was eye-opening to them that you would be a childless adult and not qualify at all for medicaid. 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 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's 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 they were higher income than they really were. these kind of voters really scrutinize who would benefit from this program 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 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's who they think it is. the good news is they're 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. it does well but mainly it does well because they don't understand what the coverage gap is. it takes me a good five minutes to explain the coverage gap in those focus groups. if we use it right up front, just know there's 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's 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 why you're talking about healthy florida. anyway, that's why there's 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 a kind of challenge 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 the issues we faced. anytime 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'm becoming anti-message the more i do this work in this environment. they really want facts, unbiased information. they really want you to be straight with them. more and more i'm leaving behind

more values based messaging and 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. you know the federal government paying 100% of anything sounds like a handout. i don't like that. don't invest better uses for their money? why are they giving 100%? they got stuck on the 10% share. that was our biggest message barrier. that was the attack we had to beat back. they got hung up on this 10%. that's a lot of money, budgets are tight, we'd have to cut education. 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. we had to address this. they are unaware that people

fall into the coverage gap. so they don't know what the problem is. 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's 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. tried and true messengers that typically work on this message in these states we got pushed back. they thought they're going to be for this because they're going to get paid more. hospitals as we know have been very vocal on this issue. i thought it would be a trusted messenger. no hospitals have an agenda. they're not trusted. their governor. governor only worked in utah. 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. the most neutral sources were the best. we talked about researchers, economists sort of doing a cost

benefit analysis. that kind of data was trusted. other messengers weren't. so these are you have to, you have to, you have to -- tough, tough, tough states. they want to help working families. 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 worn about whether we should talk about the affordable care act in these focus group or not. they had to know where the money was coming from. we had to say the money had been set aside for this purpose and if you don't use it, they're going to keep the money. 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 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 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 pln in other states. lastly, with he have to talk about the economic benefits to the states. job creation. it's not a top tier message but it does well. last big topic i want to talk about before i end is waiver ideas. 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. 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 premium. that helped us push back on that.

on co-pays, we said what if this means someone puts off getting care when they're sick because they can't afford the could-pay. you're right. let's make it $5 or $10. we talked about healthy behaviors. that was our biggest win behind incentives and discounts as opposed to penalties. so it was easy to win. work requirements were you have to. we talked 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. i don't want that. so we pushed back. 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. 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. 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 they come from. these are people with jobs in construction landscaping, child care tourism. that really mattered. it really sort of personified who we're talking about. it got rid of some of their negative impression. defining the coverage gap using researchers and economists as messengers. talking about the plan being cost neutral, really good work if we can say it cost neutral did really well. talking about the state being able to opt out at any time. that mattered in these states. talking 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. we also had to remind them, if we do nothing, 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 ]

>> thank you very much. i really appreciate being invited here today to talk to you all and just a quick word about families usa. during my time on capitol hill we faced some good fights and some bad fights. for example, there's twice on two occasions while i was working in the senate there were proposals to block grant the medicaid program, and families usa was the leading group to help. there was a point where we had 45 democratic senators, 55 republican senators, it had passed the house, came over to the senate and there was actually pushback in the community to say yeah, maybe you shouldn't do -- we shouldn't push an amendment to strike the block grant. i had a great conversation with ron 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 a self-fulfilling thing. so there was a lot of skepticism we would win but through the work of families usa, all the people in this room, we won. we won on a 52-48 vote, and so beating back block grants. the other thing is things like the aca and the c.h.i.p. expansion that happened in 1997. families usa played an enormous role there. just want to thank you all and families usa itself but all of you for all the work on those, the progress we've made over time. so sometimes as we're playing defense we have to remember that we've actually made some great progress progress, and so that leads into what i want to talk about. 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 the offense. i'm 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 education, we would expect that there are going to be efforts to cut medicaid dramatically. 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 talk about c.h.i.p., and we're trying to get it extended and reauthorize and some of the work we've been doing jointly with families usa on that and some of the messaging we've been doing. we've 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. last i want to talk about legal immigrant children and an effort we think will happen to try to roll back coverage. so if you like numbers, i will put a lot of numbers on the screen. 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's support of what we're saying and you can focus on sort of the messages. so with that said -- if i go back -- there we go. the first thing is the issue of medicaid and so we use a republican firm actually to do these polls and we asked 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? these are people already inclined to say we need to cut spending. what you can see is medicaid did very well. people said, well not medicaid and then you can see by 73/27 margin people said you shouldn't touch medicaid and i will note that medicare was at 74.

so medicaid did about as well as medicare which was really great. you can see also on the children's health insurance program it was 67/29 as well. so people said absolutely opposed cutting medicaid and c.h.i.p. the av numbers are another poll. you can see basically 70% of voters said in that poll as well, and that's american viewpoint poll, they said don't cut medicaid or c.h.i.p. and it's bipartisan democrats, republicans, and tripartisan independents all saying don't cut these programs. so we did some choshgwork with drew westin. he tested certain messages. i will put up some of these and 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're talking about in the picture, otherwise it's just a program. so talking about -- and talking about all the different types of people on the program. if you talk about kids and adults and senior citizens and people with disabilities that's the key. you can see on the dials, if you get -- if people turn the dial up above 60% they really like that message. you can see the mean test on that message about medicaid pays for immunization for kids cancer screenings for adults, people with disabilities. if that's what we want to cut, it's time to rethink our priorities and people resonated overwhelmingly with those kinds of messages. you can see kind of similar themes across the board. 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.

if they get that, they support it. and you can see 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 night was if you think you can live on $15,000 a year, then try it. same kind of thing if you really put people and kind of pit the people served by medicaid versus, you know, other insurance companies, other kind of things, that also resonates really 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 tool kit to fight those kind of cuts and efforts. so with that i'm going to transition quickly to c.h.i.p. a couple things that are important to think about and say about c.h.i.p., if you look at the polling a few years ago when we had the big fight about reauthorizing c.h.i.p. and there

were the vetoes the american public knew about the program. there were few i don't knows. over time one of the things that's happened is as we've had huge conversations about the affordable care acts and other things, many people talk about c.h.i.p. under different names. one thing is to educate people. one of the key things is people think government doesn't work. if you talk about c.h.i.p., i think a key message is it actually has worked -- it's a bipartisan program that's very successful in tandem with medicaid. c.h.i.p. and medicaid together have resulted in -- since the enactment of c.h.i.p. have cut the uninsured rate for kids by more than half. when you talk about that people go that's great. that's what we want to hear about a government program is that it actually works. now it covers over 8 million children across the country and you can see -- i just butput that

up for people's knowledge that it's really been remarkable because ininsured rate in a lot of states was over 20% and now the worst state in the country, the uninsured states are 13%, 14%. states like arkansas have an uninsured rates for kids at 6%. people can't believe it. there are southern states that have low uninsured rates for kids and it's attributable to medicate and c.h.i.p. it's a little complicated because it's a truncated system. one thing that's important in the c.h.i.p. expression was express lane eligible and allowing states to take up simplified eligibility. that expires at the end of the march. c.h.i.p. expires at the end of september. however, for states to know what the budgets are to plan we

really -- we're really pushing -- you know the message we're asking for is a four-year extension and do it by the end of the first quarter, so by march. 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's some urgency around this. and then last effort is very important. it prohibits states from detracting and cutting medicaid and c.h.i.p. eligibility. so why c.h.i.p.? the aca was purposely set to set on top of medicaid and c.h.i.p. if it goes away, the problem is it's a program set up for 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's why we are jointly -- it was purposely set up that way and we want to keep

c.h.i.p. going. we would love to see the aca extended in a way and improved so that c.h.i.p. kids would not be left worse off if it went away. what this chart really shows is the out of pocket cost for kids would go up dramatically if c.h.i.p. were to go away. so how is -- how is support for c.h.i.p.? you will see that initially people do favor it. if you ask people do you think c.h.i.p. 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. so you can see 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. it's a reminder to people what we found in the focus groups on. people go, oh yeah, yeah, yeah i know that program. yes, i love our kids in arkansas. i love badger care and so if you

familiarize people they immediately go, yeah yeah yeah, i like it. then it jumps to 74/14. that's the level of support we have and it's across the board. i'll show you that. democrats, republicans, independents, you can see strong support even with republicans. it's a 3 to 1 -- over a 3 to 1 margin of support for the program. and we also asked people are you a tea party sympathizer supporter? and even they, 66/18, which we thought was amazing. and we also asked them the question of they're 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 c.h.i.p., and amazing number from tea party folks to, no, that's not what we're talking about. so we have even tea party people saying don't cut spending. so there's often organization

inclined not to speak to them about some things and i would say on this issue their voters are inclined to say, no, you don't cut medicaid and c.h.i.p. 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 to -- it's not -- on so many issues we poll on, there's definitely a gender gap, women are more supportive on health issues than men. what's really interesting here is that for young people there's sort of a different take. the gender gap is actually among older republican men, white men, actually the one demographic that's sort of a little bit of a problem, like it's more closer to 50/50 but if you look at younger men, they polled just as well, and even in the two polls we have done on this slightly better than even younger women. there's something going on here in this new generation. it gives me some hope that we'll

have a lot of -- men are coming around. i say this now because later on i'm going to tell you something bad about men so, you know, it's kind of embarrassing. a couple polling con cluk collusions is the biggest challenge for c.h.i.p. is not that there's opposition, it's that people don't know about it. educating people about it is very important. ths one of the reasons we've been working really closely with families usa on op-eds and getting editorials and getting the information out in the public, social media, et cetera. the other thing is there's not blowback on c.h.i.p. over the debate over the affordable care act. so we were really worried that republicans who, you know, 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 c.h.i.p. in the same boat even

if they're opposed to obamacare they still are inclined to support c.h.i.p. a good message for republicans is to focus on its bipartisan, that it's state run and it's successful. and so the message that we got from american viewpoint, a republican firm, they thought the overriding message was bipartisan children's health care that works for working families. it gets back to the point of focusing on the population it serves and what it does for them, provides immunization 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 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's still a lot of economic uncertainty in the public and that worked really well. testimonials so 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 a key coalition partners. things not to do is don't compare to to medicare. there was something to say we should do for kids in c.h.i.p. what to do with seniors in medicare. republican men go, no i don't think so. because they have that sort of family bubble perception about kids. that's a parents' 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 problem. don't make comparisons like

that. and i think that's the most 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 being losses. one of the best message was this issue of don't gamble with children's health. that's been one of the most powerful messages is we talk about c.h.i.p. it's a good program, it works, it's bipartisan. don't gamble with children's health. if it's over 60 people really support it. that's not a support level. that's how high they turn up the numbers. 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. that's a really strong message. last we want to talk about 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. some states have taken the option, some have not, but there is -- there's highly likely an effort going to be to repeal that in this congress, and so one of the things that we take note much is as progressives, we tend to think that if we just come up with another argument. so i worked on the first ikea bill in 1987 and over time we just kept adding arguments. we'd say and then there's this point and then there's this point. we had a 12-page fact sheet we'd take up to the hill saying the 700 reasons why you should support the immigrant children's health insurance program -- improvement act. what we found in the 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 a health care coverage. a kid with cancer a kid in need of eyeglasses. they can't wait for 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 -- rush limbaugh voters. so you don't need to get into all these other issues. 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 is asking pregnant women to wait five years it's kind of stupid. just makes no sense at all. but if you say no child should wait five years to get health care coverage and their parents pay taxes it was fascinating to see what happens, and we did some work with the national immigration lossaw center on this. what was really interesting is women and democrats so again this is going to be -- this is women are smarter than men point

here, is that an argument, the support level 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 into the frame of taxes, then they go, whoa, taxes. 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 health care and this point of 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's actually a hard thing for them to say because then they have to get into deeming 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. with that, thank you. [ applause ]

>> thank you. 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 people around to pick them up. in the meantime let me turn to you two and ask you a question. bruce, in terms of congress i wrote down a really simple message around c.h.i.p. 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 the same kinds of messages work? >> go ahead, bruce.

>> so on congress i think that does work. i think that, you know, 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 c.h.i.p. nor were they around for the message of the affordable care act. so i think there is a little bit of educating them on what medicaid and c.h.i.p. are and pointing out to them that their bipartisan because for many of them all they've 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 to support, you know, the children's health insurance program and they're like what? because they've only worked for -- they've only voted no no, no, voted to repeal. so they're like 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. >> i would just add in the past i have done focus groups with hill staff members and with state legislators about both c.h.i.p. and medicaid and i concur with bruce. don't think they know a lot about these programs over they're that different from voters. they really need a lot of education around c.h.i.p. and medicaid so that's a place to start. what the programs are, who is in the programs and why they matter. >> 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? >> that's 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 tried to get from them who they would trust. we did try to go down a level. we tested mayors in a number of 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 -- we were just talking as we do more research on this we think we want to bring in faith leaders. we think they're 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 sort of lower level political leaders. >> okay. and the best messengers you found were sort of neutral sources, researchers, things like that. >> exactly. >> so in advocating for medicaid expansion, how do red state conservatives respond to messening about the need to keep funds in order to sustain rural hospitals that are at risk of closing? >> great question. we talked about rural hospitals.

so we asked in these states -- we knew in north carolina there had been hospital closings that had been an issue. 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 short andcharlotte and it was sort of unbelievable to them that a hospital could actually fail. what they said and the pushback we got was if a hospital fails, it's because of other kinds of things, bad management, not because of this. we pushed quite hard on it. i think if we'd gone to a rural area, i think 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 good but local hospitals as a messenger was proven problematic among these kind of voters. >> to the public, right? >> yes. to conservative voters who we were talking to. >> and i think if i could add to that i think that to a hill staffer it's a different -- that's kind of a different -- because they're going to respond -- in lots of rural areas, of course those are the biggest employers. so that will freak out politicians and stuff, but different messenger. >> different message for different people. the hospital case may be persuasive for the actually lawmaker if not the public. i have a question here for bruce. i misread it first. i thought it was for brad. brd isn't even up here. for states that currently haven't picked up the ikea 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's a place to push for that during our c.h.i.p. funding advocacy? let me rephrase. where are we on icia. >> i could kick it to brad. about half the states have taken up the option which has been great and we certainly would love to see other states do it. there's 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, you know allowing kids to wait five years. that's not -- that's terrible and it does resonate. so i think, yes i think at the state level that is something to continue to push. and 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's 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. we don't want a scenario where some immigrants some places can get it and other places they can't ever get it. so i think kind of a offense defense/offense agenda. >> i have a question 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's a footnote to that, which is over time that goes down. did either one of you want to talk about that? >> well, what i can tell you

with voters, it's an effective message.voters, it's an effective message. they really believe over use of the e.r. is a cost-driver. i always like when a message seems intuitive like that. of disregarded the oregon 12ud day. it's really complicated, the talk about goes up and goes down. ime it it seemed intuitively right to voters. >> i also believe there was a recent health article where they are bestowing lots of evidence that the expansion of the affordable care act is seeing decline in some states, too. i think there's more evidence coming out that it is true. that e.r. use is down. >> i think we should use it. >> okay. for bruszce, what's the level of support for refunding c.h.i.p. among state medicaid directors. if i were you, i would take this

as an opportunity to report on state officials over all. >> the good thing is the house and senate asked the governors to write letters to them about what they think about c.h.i.p. and, to be honest, who knew what they were going to say. and, fortunately we've -- a lot of you all did work on that and really talked to your governor's office and your c.h.i.p. directors and your medicaid directors to get good directors. 39 governors responded and 39 said we want c.h.i.p. re-extended and reauthorized. sam brownbeck said i want a five-year extension to c.h. imt p. she's like, sam brownbeck said five years. so it's great. and i would, you know having worked for a governor, those directors wrote those letters for the governors. so the c.h.i.p. directors are supportive. the governors are supportive. i also think another great thing to try to do is have state

legislators. if you guys are close to your state legislators have them write congress and say hey, we need this to happen and we need it to happen now. we're in the middle of budget and we need to know what's going to happen in the middle of this program. we need to know. i would, for example sarah hatch who is the finance committee chair, the governor in governor herbert in utah, said i need six months and part of the reason is my budget --ly legislature goes out of session in march. so that was great for us because we're actually pushing for this to happen before the epd of march. and, so, he said i need at least six months, which is the end of march. >> i'm just going to turn back into a government affairs person and ask people, have -- and i know i asked this already in some of the workshops, how many of you have already been to the hill this week or plan to go to the him in the next few days while you're here. okay. that's great. in terms of ch.h.p.i., you

know, the national governor's meeting is right around the corner. we've got republican and democratic supporters strongly for c.h.i.p. so another thing for you all to do, look up your governor's letter, familiarize yourself with it. ask your governor to meet with their delegation and push for c.h.i.p. funding. it's essential for their budget-making. okay. i've got -- i think this is going to be our last question. and it's -- it's about -- you've asked for a four-year extension of c.h.i.p. why a four-year and why not make it permanent? >> i would loef for it to be permanent. but one of the things that happened is you saw the effort was extended to 2019. so there's some of those things happening at the same time.

so we can have a complete debate about the future of c.h.i.p. and there's some thought that maybe we can do some improvementeds to theimprovesment improvements to the affordable care act and so that by that time, the affordable care act might be more comparable. there's things that she's got to fix about it. we're not in favor of the two-year because we don't think that there's any way in a congress that's still talking about repealing obamacare. they're not going to go back and try to make improvements to it yet. but the hope is that over time, that will change. we want at least a four-year. i would love a permanent extension, but i don't think congress is going to do that. we're pushing for something that's more reasonable. >> okay. taung very much. before we wrap up, i just want to make one last announcement.

again, we want you to be back here in the ballroom at 12:20 because senator cheri brown from ohio will be speaking at 12:30. if you're from ohio, come and sit up front so you can say hello. with that i want to end on a high note and warmly thank our two speakers, mike and bruce. [ applause ] >> ron, thank you. it's a great honor to be here and to be again with families usa and the terrific work you co. thaing, the ohioans who are here and the folks from the asoeszuation of food bank and from the first congregational church. my wife and i were married in the congregational church an all-affirming church. so thank you for that.

ron pollock's work has been terrific. i've known ron for 20 plus years. some of you know this and most of you don't. ron grew up in new york. one of his best friends that he played stick ball with that he says couldn't hilt his curve ball is jerry springer. did you know that? how many of you knew that? so it's, like, one person knew that. two people knew that. that's true. anyway. so anyway, ron's leadership has made such a difference. you should be so proud of what you have fought for in this country, in this congress that, you know, there's a story franklin roosevelt in the early mid 30s met with a group of progressives on -- i don't know what the issue was. and he said i agree with you. now go make me do it. and it really is the role of activists to make people of like

mind in congress, people who sort of lean our way in congress, people who might be indifferent in congress but to get all of us to do the right thing. i have, since i've offered 15 years, i've worn this pin on my lapel. it's a picture of a canary in a bird cage that was given to me by a steel worker in a worker's memorial day rally. the story of the canary, if the canary died of toxic gas, he had no union strong enough or government that cared enough. in those days a baby born in this country a life expectancy of 45 years or so. today, it's 2 to 2 1 halve decades longer, because of the act vichl of you and your parents and your grandparents. none of these things happened by themselves. whether it was food safety, mine

safety, social e social security, civil rights, women's rights, protections for children, medicare, medicaid safe drinking water, clean air, all of those things, affordable care act, all of those things happened because of activists. and there's no group -- one guy is clapping. the ohio people know to clap for that. plauz plauz. >> and this group this families usa understands that, i think as well as any group of activists and the people you represent, the organizations you rep sebt e sent around the country, perhaps better than anyone. for those who i have not met, and that's most of you, this is my real voice. i'm not sick, i don't smoke. i just talk this way. and my wife and i were at the democratic convention a few years ago and we were -- and my wife is a pulitzer prize-winning writer. she's got the best facebook, ever. her name is connie schult skrks. z.

connie and i worked at this event. and it feels in a room about this size. and we were all kind of packed. there were no chairs. we were all kind of packed together. and there's a little stage. a couple of senators and i went up and spoke. i began to speak. this is a true story. this guy is substantial doubting right next to connie as i start speaking and i turned to her and said i hate that guy's voice. she said really. and he said yeah, when that guy speaks it's like fingernails on a chalk board. i can't stand it. you know when i really like it? i like it when he wakes me up in the middle of the night and says i love you, baby. [ laughter ] >> a year ago at this time in a colder snowier place in washington, i was at martin luther king day celebration, early 2014. and a minister stood up and said something that you all know, but

he said it better than anybody i've ever heard say it. he said your life expectancy is connected to your zip code. we all know that if you grow up in our state, my state if you grow up in the east side of clooef land, am la cha versus if you grow up in shaker heights or scarsd ale, new york, you have a better chance in life or a worse chance in life in terms of everything, quality health care, education, social support necessary to succeed. it's something that most of us know and most of us don't think about and most of us fail to talk about it very much. 50 years ago, the poverty rate was 26%. today it's around 15%. it's still far foo high.