The Impact of Policy in Healthcare

Health ExChange Academy

Advocating for Change

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Understanding How to Impact Health Policy1

A dvocating for Change

U nderstanding H

ow to Im

pact H ealth Policy

H ealth

ExCh ange A

cadem y

1

Advocating for Change | Understanding How to Impact Health Policy

Written by Harry Snyder, with assistance from Matt Iverson

Copyedited by Lisa Black Designed by Lane + Lane

Copyright © 2006 by the Center for Healthy Communities of The California Endowment. All rights reserved.

This manual was published by the Health ExChange Academy of the Center for Healthy Communities.

Special acknowledgment to The California Endowment’s Public Policy Director, Barbara Masters, for her

guidance and insight in developing the framework for Advocating for Change.

inside back cover

1 Advocating for Change | Understanding How to Impact Health Policy

Advocating for Change

Understanding How to Impact Health Policy

What is advocacy?

How is it important for your work and building the community you serve?

How is advocacy done?

Who are the players?

Foreword

The California Endowment places a strong emphasis on policy change activities,

including advocacy, with the belief that policy change is necessary to make meaningful

and lasting improvement in the health of Californians. Although no single policy or

system change will achieve the ultimate goal of a healthier California, The Endowment

firmly believes that everyone has a role to play and that all organizations can participate

in the advocacy process.

To that end, The Endowment’s Public Policy Department and the Center for Healthy

Communities have developed Advocating for Change as part of the Center’s Health

ExChange Academy. Designed to provide you with the fundamentals of advocacy and

the tools to put that knowledge into practice, Advocating for Change is the first in a

series of trainings to help staff at nonprofit organizations become more effective leaders

in improving community health.

Special thanks are due to Harry Snyder, an advocate well-known for his prior work at

Consumers Union, for writing this manual. The training program itself was developed

by Harry and the team at the National Community Development Institute: Omowale

Satterwhite, Shiree Teng and Diana Lee.

It is our hope that this manual and training will help you in your work in advocating for

improved health outcomes in California’s most underserved communities.

Sincerely,

Robert K. Ross, M.D. President and Chief Executive Officer The California Endowment

1. HeAltH Policy AdvocAcy: An intRodUction 1

2. AdvocAcy StePS to MAke cHAnge HAPPen 6

Getting the Facts—Research and Data Collection 6

Building Support—Organizing and Coalition Building 10

Making a Plan—Develop Goals and Strategies 14

Communicating Your Message— Informing the Public and Decision Makers 18

3. AdvocAcy PlAceS WHeRe deciSionS ARe MAde 28

Changing the Law 28

Working with Government Agencies 30

Working with Health Care Institutions 32

Working with Private Companies 34

Using the Ballot Box: The Initiative and Referendum Process 36

Using the Courts 37

Direct Group Action 39

4. RefeRenceS 42

5. WoRkSHeetS 57

Table of Contents

Advocating for Change | Understanding How to Impact Health Policy 1

Health Policy Advocacy An Introduction

This manual will help grantees of The California Endowment and oth- ers understand advocacy, the world of health policy advocacy, how advocacy is done, and what part each person can play. Health policy consists of the rules governing health issues, for example, requirements for culturally and linguistically appropriate health services, worker safety practices, or limits on air pollution. These rules or public poli- cies decide how a diverse population receives appropriate health care, what worker safety protections will be required, and how much pol- lution can be released into the air. Policy change is a shift in the rules that allows for new ways of doing things, such as more culturally and linguistically appropriate health services, stronger measures to prevent repetitive stress injuries, or stricter standards for release of pollutants. Advocacy is a way to change both the health policy rules and resource allocation decisions of government and private institutions.

In order to bring about better health, it is important that people who are working to improve the health of California residents know the processes for changing the policies and practices of government and private institutions. Service providers, whether they are caseworkers, public health educators or clinicians, know firsthand the roadblocks to delivering those services. They are in a strategic position to identify problems, to understand the ways that will work to solve the problems, and to engage their clients and constituents in the process. Researchers and health policy specialists also have concrete ideas about how to im- prove health. Those with hands-on experience and other expertise bring credibility, enthusiasm and commitment to the process of improving and protecting health in California. The California Endowment wants the people and organizations that are affected by and understand health problems to have the tools to solve them. Understanding health policy and health policy advocacy is the first step to gaining those tools.

Advocacy projects to improve any aspect of health can have the add- ed benefit of building the capacity of communities to move their own agendas. These projects can include low-cost housing, more and better jobs, a cleaner environment, or safer streets—all of which can contrib- ute to improving community health. Building community capacity to

“Never doubt that

a small group of

thoughtful, committed

citizens can change

the world. Indeed, it

is the only thing that

ever has.”

— Margaret Mead

1

2 Advocating for Change | Understanding How to Impact Health Policy

effect change should be built into every advocacy campaign, both to strengthen the campaign and to consciously build skills for the future.

Advocacy can be done in many ways, including: seeking changes in government agency policy or practice, working with private businesses or health care institutions, changing laws, introducing ballot initiatives, taking direct group action, and, when necessary, litigation. Often, one or more of these strategies is used to bring about better health or to protect what is now working effectively. The same four steps to make change happen are used in every place where health policy decisions are made. However and wherever health advocacy work is done, you will need to complete these steps:

1. Get the facts.

2. Organize support.

3. Define the problem and make your plan.

4. Communicate a clear and compelling story of what is wrong and what should be done.

These pages explain the basic steps involved if you become part of an advocacy campaign for better health. The References section at the end of this manual provides resources for additional, in-depth guidance. These sources include information for the sustained course of action needed to remedy serious problems inherent in an advocacy campaign. Changing health policy is hard work and can take time, but it is essential for improving your community’s health. Examples of prior campaigns are used throughout the manual to demonstrate how the work is actu- ally done; they show the concrete results and improvements in health that advocacy can bring about.

Advocating for Change | Understanding How to Impact Health Policy 3

Advocacy Works on Many Levels

for some time, consumer and nutrition advo-

cates argued that Mcdonald’s and kraft foods

produced and marketed products that are con-

tributing to the growing obesity in the nation.

Advocates engaged in a variety of strategies

beginning with publicizing research data and

analysis highlighting the negative aspects of

the companies’ practices and products. law-

suits were threatened and in some cases filed.

Public protests and demonstrations were held.

new government laws and regulations were

discussed and introduced. Advocates wrote to

and met with company executives. All of these

advocacy strategies, which were carried out

in various places where decisions are made

(including administrative agencies and the

legislature), were rebuffed by the companies

and met with denials and excuses. But with

an accumulation of pressure, both Mcdonald’s

and kraft felt the need to announce their

intentions to alter their policies, reconstitute

their products, and change their marketing

practices aimed at children. each one of the

advocacy efforts contributed to changing poli-

cies at kraft and Mcdonald’s, which will lead to

better health.

HoW cAn yoU Be An AdvocAte?

The skills that already make you successful— knowing what is important to your work, working with others, planning your efforts and communi- cating what needs to happen—are the same skills used for advocacy. People and organizations pro- viding health services often work to change the rules so they can serve people more effectively or serve more people. Researchers and health policy analysts identify causes and potential solutions to save lives, reduce disease or make health care more efficient. Many people do not recognize that they are already advocates when they work to im- prove the delivery of health care or to get more money for a budget.

Each person and organization uses their own style to advocate. They use the style they are comfort- able with and that has been effective for them in their work. You don’t need to go to court or hold a demonstration to be advocating, and you don’t need to be a “health policy advocate” to advocate. Advocacy is working on behalf of others to make systems better or to protect what is now working. To be effective, advocacy involves a broad range of people with different skills and commitment of time, from academics to community activists.

It is important to understand that changing the policies of public and private institutions can help solve health-related problems. It is also important to know how those changes are influenced and what your role can be in helping to bring about improvements in health through advocacy. The California Endowment is committed to helping grantees and others in the essential work of im- proving local, state, federal, as well as corporate policies affecting health.

Health Policy Advocacy: An introduction

4 Advocating for Change | Understanding How to Impact Health Policy

Restrictions on Legislative Advocacy

lobbying has come to mean trying to convince

someone to do something, such as lobbying a

friend to go to your favorite restaurant or lob-

bying the mayor to open a health clinic in your

community.

However, the federal internal Revenue Service

defines lobbying very specifically. Although

lobbying is an important component of most

advocacy campaigns, advocacy encompasses a

much broader range of activities. Any advocacy

effort that does not meet the iRS definition is

not considered lobbying.

there are two kinds of lobbying: direct and

grassroots. direct lobbying has three elements

and is defined as

1) a communication with a legislator

2) about a specific piece of legislation

3) that expresses a view on that legislation.

grassroots lobbying is a communication with the

general public that seeks to influence them to

take action by including a specific “call to ac-

tion,” such as asking people to write their legis-

lators. the communication must also be about a

specific piece of legislation and express a view on

that legislation.

the iRS sets limits on the amount of money

that may be spent on lobbying by a 501(c)(3)

organization that has made the “501(h)

election” (see References p. 45 for Alliance for

Justice). However, it is important to understand

that these limits do not apply to non-lobbying

health advocacy such as educating an elected

official about an important health issue,

working on an administrative regulation or

organizing community support.

it is also important to understand that the iRS

regulations are not intended to prevent leg-

islative advocacy or lobbying by nonprofit or-

ganizations, although private foundations are

prohibited from lobbying or designating grant

funding for lobbying purposes. According to

the Alliance for Justice, “congress has stated

that influencing legislation is an appropriate

and legitimate activity for charitable organi-

zations. in 1976, it passed legislation giving

public charities the right to lobby up to defined

percentages of their annual expenditures.”

know the rules. for more information on how

501(c)(3) organizations can advocate and lobby

effectively, see Alliance for Justice’s Worry-

Free Lobbying for Nonprofits, which describes

how nonprofit groups can lobby within the

iRS regulations.

Advocating for Change | Understanding How to Impact Health Policy 5

An AdvocAcy teMPlAte

This Template is an overview of the two major parts of the world of health policy advocacy described in this manual: Advocacy Steps to Make Change Happen and Advocacy Places Where Decisions Are Made. The illustration Advocacy World on this page provides a way to visualize all the parts of any advocacy campaign and how they work together. The sections that follow discuss the four Advocacy Steps to Make Change Happen essential to any advocacy campaign and the Advocacy Places Where Decisions Are Made in which the steps are used. Almost every campaign to change health policy will require: 1) knowing the facts, 2) getting others involved, 3) making a plan, and 4) communicating with others about the problem and how and why it needs to be solved. These four key Advocacy Steps to Make Change Happen are necessary for any effort to change policy. This is true whether you go to court or to the legislature, or choose another Place Where Decisions Are Made for your campaign to improve health. Examining the Considerations and Pluses and Minuses described in Advocacy Places Where Decisions Are Made will help you decide which way of working is the best strategy for your campaign.

Health Policy Advocacy: An introduction

Advocacy World

SolUtionS

Steps to Make change Happen

Building Support

Communi- cating Your

Message

Making a Plan

Getting the Facts

Legislature

Government Agencies

Ballot Initiatives

Courts

Businesses & Other

Organizations

Places Where decisions Are Made

Direct Action

Health Care Institutions

6 Advocating for Change | Understanding How to Impact Health Policy

getting tHe fActS– ReSeARcH And dAtA collection

To change health care you need to be able to show there is a problem with the current situation—for example, lack of coverage or cure, lack of services, or lack of information.

Defining the problem requires getting and understanding the facts. Finding out what is wrong and analyzing why there is a problem also helps you identify potential solutions. To improve health care you will be asking the public, the media and decision makers to rely on what you say and then to take the action you recommend for solving the problem. Your credibility will be on the line and with it your ability to be effective. You must know all you possibly can about the situation you want to change, including viewpoints on all sides of the issue, in order to give a complete and accurate picture.

Getting the facts and analysis you need is usually pretty straightforward. You will probably already have much of the basic information you need, as well as the contacts and connections to obtain additional information and help. You can rely on the skills and experience you are using effec- tively now to do the additional research and fact finding. To start your work, you will need to present clear answers to the following questions.

• Who is being hurt and/or what needs to be corrected?

• How are they being hurt? How can you describe the problem? For example, is the problem lack of coverage, information, or cultur- ally appropriate care; no money for prescriptions; no transporta- tion to health care; or an unhealthy environment?

• How serious and/or widespread is the problem?

• If left unaddressed, will the problem get better or worse?

• If worse, how so?

• Why does the issue matter?

• How has the community been affected?

Advocacy Steps to Make change Happen

To change health care

you need to be able to

show there is a prob-

lem with the current

situation—for exam-

ple, lack of coverage or

cure, lack of services,

or lack of information.

2

Advocating for Change | Understanding How to Impact Health Policy 7

Advocacy Steps to Make change Happen

To design an effective campaign strategy, you should know the following:

> if the problem is long-standing, why has it not been resolved?

> What agencies or organizations are responsible?

> What laws or rules apply?

> What reasons are used to explain the situation?

> Who knows about the problem?

> Who thinks there is a problem?

> Who thinks there is no problem?

> What are the solutions?

> What are the politics of the situation?

> Who benefits?

> What actions, if any, have been taken?

> What reports or news accounts have there been?

> What has happened in other areas? Have workable solutions been found?

Getting a government agency to gather the needed facts and do other research is often the first effort in an advocacy campaign. Community groups build their case by using government data and reports to add to the information they gather from the community and other resources. The thoroughness of your presentation of the facts, including showing that people are being harmed, along with your analysis of the problem, will influence the public, the media and the way officials respond to your request for change. Being able to describe specific solutions makes your case even stronger.

Getting the Facts on Lead

in 1992, PodeR, a grassroots

group organizing families for

environmental and economic

justice in the Mission district

of San francisco, realized that

many children were suffer-

ing from lead poisoning. they

did research and found stud-

ies that showed lead-based

paints were often the cause of

lead poisoning in children and

that many homes in the Mis-

sion district were older and

contained lead-based paint.

Using this information, along

with other data and local sur-

veys, they were successful in

getting a comprehensive en-

vironmental lead Poisoning

Prevention law and program

for all of San francisco.

8 Advocating for Change | Understanding How to Impact Health Policy

Where to find the information There are dozens of information sources with answers to the previous questions.

Books, Newspapers and Periodicals Read the available literature on the problem and its history, not only to know everything you can, but also to identify those who may be helpful and those who may be part of the problem.

The Internet A search of the World Wide Web may uncover information about your problem and provide links to organizations on the same issue in other sites.

Government Reports and Documents Your efforts will gain credibility if they are supported by information from government sources. A credible campaign makes it difficult for others to deny that a problem exists. You may have to file a Freedom of Information Act (FOIA) or Public Records Act request to get the mate- rials you need (see References pp. 42 and 48).

Organizations and Individuals It is extremely important to learn the views of other organizations and individuals interested in health issues. You’ll want to confer with like- minded individuals and organizations not only to get the benefit of their experience but also to enlist their support. You should also explore the positions of potential opponents, not only to better understand their perspectives but also to help you incorporate effective arguments against their positions into your action and your media materials (see Refer- ences pp. 44 and 45).

Advocating for Change | Understanding How to Impact Health Policy 9

Advocacy Steps to Make change Happen

Academic Sources Schools of public health and other academic institutions can pro- vide a great deal of unbiased research and analysis to help you clarify a problem and identify solutions. These and other organizations are not ivory towers, but practical resources looking to help communities solve health problems. It is also possible that graduate students may be willing to assist you in finding facts and existing studies to guide you. (For a thorough list of academic institutions specializing in public health, see References p. 47.)

Data Sources There are research organizations and data sources that are intended to be helpful and accessible to community groups. They can direct you to search engines and other sources for finding information relevant to your community’s health issues. The California Health Interview Sur- vey (www.chis.ucla.edu) and the Urban Institute’s Health Policy Center (www.urban.org/content/PolicyCenters/HealthPolicy/Overview.htm) are good places to start.

➜ You can use Getting the Facts: Researching the Problem on p. 58 of the Worksheets to guide your work.

➜ Information on Getting the Facts can be found on p. 48 in References.

10

A single individual or

organization can take

action, but the likeli-

hood of success is far

greater if a coalition of

groups and individuals

join in the work.

BUilding SUPPoRt — oRgAnizing And coAlition BUilding

A single individual or organization can take action, but the likelihood of success is far greater if a coalition of groups and individuals join in the work.

organizing and coalition Building Organizing is working with individuals in the community to develop a broad-based understanding of what is wrong, what needs to be done, how to work together, and who else will be working for change, and also seeks to motivate people to join in the campaign. Coalition build- ing is the work done to get groups to work together in a campaign. Organizing and coalition building are two sides of the same coin: get- ting broad-based support for improving health.

organizing goals The purpose of organizing is to increase the number of individuals in- volved in and supporting the movement for change. You will want to educate and inspire people in the community and others concerned about health to join in and work for change. There is strength in num- bers because your problem solving will be more relevant, you will increase the capacity of your community to solve its problems, and you will strengthen the community’s political clout to bring about change in the future.

Successful coalition components As you start your work, try to include individuals and organizations that are widely recognized and respected, both within your community and by the larger public. Having a prominent person as a leader and strong organizations as members can make it easier for others to join the coalition. As you go forward with building a coalition, try to reach out to politically diverse groups to participate in a coordinated and structured effort. Remember that the broader the political representa- tion, the more powerful the effect. It is much harder to dismiss an effort that is supported by a wide range of organizations, particularly if those organizations are often not on the same side. Most groups working for better health may be willing to be part of the community effort if you recognize that different organizations can help in different ways, ways that are consistent with their individual priorities and resources.

Advocating for Change | Understanding How to Impact Health Policy

Advocating for Change | Understanding How to Impact Health Policy 11

Advocacy Steps to Make change Happen

Your coalition should include organizations and individuals who have experience with health-related issues and with the community. The success of a coalition depends on many factors:

> everyone must have the same fundamental goal, a clearly defined and agreed-upon plan, and a united position and strategy.

> All parties need a clear understanding of how the coalition will function.

• Leadership must have the time, skills, experience, resources and coalition support to do the job.

• Each coalition member’s level of participation should be well defined. (Can an organization only sign on, send a letter of support, supply resources or can it participate fully?)

• Distribution of work should be undertaken according to each member organization’s strength, resources, capacity, organizing experience, research, use of media, negotiation skills or leadership.

• There must be a commitment to full, thorough and frequent communications.

• Assigned decision-making authority should be agreed to by all members.

• A defined style for the campaign (e.g., in-your-face, diplomatic, high media visibility) and the sharing of credit are part of the plan.

• Accountability of each group for its part of the whole effort should be in place.

> All members must commit to be in for the long haul and to support everyone else’s interests until the job is done. no selling out or side deals.

> the coalition members must present a united front, with designated speaker representatives who have defined decision-making authority.

> the coalition members should regularly assess their progress and impact.

> All successes will be celebrated and acknowledged by all members.

Basic Coalition Principles

• Clear agreement on commitment to issue

• Clear agreement on policy agenda

• Clear agreement on coalition structure

• Clear agreement on roles for members

• Clear agreement on resources committed

• Tasks delegated to best-qualified people

• Clear communication, ongoing and regular

• Actively build capacity/ skills of members and groups

• Share credit, share victories, share setbacks

• Regularly review strate- gies, roles, communica- tion and other coalition operations

12 Advocating for Change | Understanding How to Impact Health Policy

Coalitions can be as formal as those with a letterhead and a separate office or as informal as an agreement to sup- port a single goal. No matter how you work, you want supporters to sign on as sponsors of the effort. But if a coalition partner does not want to join fully in the work, a letter of support or testimony at a public hearing should be welcome. Coalition members need to be con- cerned about the organizational needs and capacity of all supporters, and not assume that every group can participate in the front line of the campaign.

tensions Changing the health system is diffi- cult work and community coalitions must support a shared vision of what to do and how to do it. Your fact finding and analysis may lead you to think you know what is wrong and what needs to be done. But for effective coalition building, you may want to present the community members with the infor- mation and have them decide what they think are the problems and solu- tions. In this way, they are making key decisions and taking ownership of the campaign. It is a strategic decision that helps build a solid coalition. If there is no agreement on a solution or if com- munity members or organizations can’t agree on roles, leadership, control of resources or strategy, the work is much more difficult and less likely to succeed. Negotiating agreement on these issues may require patience and compromise.

California Coalitions Pay Off

in 1994, consumers Union objected when a nonprofit

health insurer changed into a for-profit business

enterprise. it appeared that the assets of the

nonprofit would be absorbed into the new business,

resulting in a loss of charitable dollars that could be

used to improve health in california. despite the best

efforts of consumers Union, the government approved

the change without addressing any of the group’s

concerns. in order to continue the struggle, consumers

Union reached out and helped form a coalition of

more than 90 groups from throughout california

representing seniors, children, consumers, minorities,

and low-income and faith-based communities.

the broad-based, diverse membership of the coalition was

a clear message that many people from many viewpoints

thought something was wrong and that something

needed to be done to protect the public interest.

Working together, the coalition issued reports, filed a

petition, contacted the media and elected officials, and

presented evidence at hearings and meetings. forming

the coalition and advocating together for a solution

made the public, the media and government decision

makers pay attention. the coalition accomplished

what the individual group could not. the government

changed its ruling and required that the charitable

dollars be held for improving health in california.

Advocating for Change | Understanding How to Impact Health Policy 13

Advocacy Steps to Make change Happen

Red flags When the opposition to your efforts is strong and perhaps hostile, you need to maintain internal accord. Allies, partners, co-workers or sup- porters who become unhappy and break away from the agreed-upon plan may undercut your work. Warning signals should go up if

• coalition communications are not up-to-date.

• information is not fully shared and available.

• differences of opinion among coalition members are not resolved and set aside.

Remember This is a campaign. Your audience is not just the legislature or courts or an agency, it also includes the media and the general public. If your campaign involves a large, diverse coalition of groups and individuals, the media (especially editorial boards) and the public will perceive that there is a broad consensus on the problem and the solution.

This is building your community. In addition to solving a specific health problem, advocacy campaigns are used to build the community’s capacity to work together for better health.

A strong coalition of groups and individuals makes the work easier, more exciting and more likely to succeed.

➜ You can use Building Support: Inviting Others to Join on p. 62 of the Worksheets to guide your work.

➜ Information on Building Support can be found on p. 49 in References.

If your campaign

involves a large, diverse

coalition of groups and

individuals, the media

(especially editorial

boards) and the public

will perceive that there

is a broad consensus

on the problem and

the solution.

14 Advocating for Change | Understanding How to Impact Health Policy

Every advocacy

campaign to improve

health, whether it is

a statewide or local

effort, requires a plan

to get from the prob-

lem to the solution

and includes a road

map of the steps to be

taken along the way.

MAking A PlAn — develoP goAlS And StRAtegieS

Every advocacy campaign to improve health, whether it is a statewide or local effort, requires a plan to get from the problem to the solution and includes a road map of the steps to be taken along the way. A cam- paign can be any sustained work for better health. This can include a campaign for a hospital to provide appropriate cultural and linguistic health services or a campaign for universal health care. Big or small, health campaigns are important and their success depends on the fol- lowing elements being spelled out in your plan:

1. A clearly defined problem

2. A clearly defined solution and interim goals

3. An assessment of resources

4. A clear strategy

definition of the Problem It is essential that the community affected by a perceived health issue define and agree on the problem they think needs to be fixed. For ex- ample, different people may have differing views on the nature of the asthma problem, with one concerned about the environmental pollut- ants causing asthma attacks and another concerned about inadequate care and lack of medications to prevent and mitigate attacks. Although both concerns are important, the differences must be resolved through community consensus to determine the exact problem the coalition wants solved, along with a united position of working together to reach that goal. Defining the problem is a way of bringing people together. It is also the way you can test whether or not you are going after the right solution. Having your problem clearly in focus helps you avoid being divided, stay on task and communicate to others exactly what must be fixed. In this case, the community might agree that the problem is too many children are suffering from asthma.

Advocating for Change | Understanding How to Impact Health Policy 15

Advocacy Steps to Make change Happen

definition of the Solution and interim goals You must decide what solution will meet community needs for im- proved health with clearly defined short-term goals and final goals that will solve the problem. Using the example of asthma, the community might decide that the state needs to adopt laws to significantly decrease air pollution and that the county should provide comprehensive pre- ventive and treatment services through asthma clinics. Targets for the definition of a “significant decrease” and for what constitutes “compre- hensive” services are essential. Clear targets help define a bottom line so you can be sure that you continue the campaign until you achieve fundamental change, and so that you know when you get there.

Examples of short-term goals might be: to educate and organize community members; to form a coalition of community and other interested groups; to conduct surveys and research to document the problems; and, using the media and the Internet, to build support and create public pressure for change. These are measurable short-term goals that allow the coalition to see that it is moving forward toward the twin objectives of decreased pollution and creation of new clinics. Meeting these interim goals will demonstrate to the community and to the public that this campaign is serious about diminishing the impact asthma is having on the community. Planning should include specific timelines for reviewing interim goals so that the coalition will regularly assess its progress and make changes, if necessary, about how to go for- ward. Regular evaluation of how you are doing is a way to ensure that the coalition is working toward success.

Assessment of Resources Part of the planning process is to assess the resources of the commu- nity and potential coalition members, particularly the ability to work together. Is there a history of working together or working separately? Can there be agreement on leadership? Are there enough people with enough skills and experience to succeed? In addition to leadership, you need people with the skills to do surveys and to gather facts and infor- mation that can be used to document the problems. Someone will need to be able to get people out for meetings, as well as for news confer- ences and other community events. You will need speakers who can represent the community or coalition. Is there a way to pay for supplies

16 Advocating for Change | Understanding How to Impact Health Policy

and out-of-pocket expenses, places to meet, and computers to use? Are there phones to call the media and to call the community for meetings? Is there someone who can manage e-mails and a Web site? If necessary, you can ask those who have these capabilities to join the campaign.

Most of the logistical needs can be provided by local churches, com- munity organizations and individuals. But people’s time for the factual research and community surveys, for organizing and communicating, for drafting notices of meetings, etc., must be realistically assessed. The actual out-of-pocket dollar costs can be minimal, from zero to a few hundred dollars for telephones and copying. It is the “people time” that is needed most.

It is possible to find funds for advocacy campaigns. Individual donors may be willing to contribute to an effort to solve a community health problem. In some cases, special public fund-raising efforts can be initi- ated to pay for a campaign such as placing an initiative on the ballot. Foundations interested in systems change, civil society, environmental justice or other aspects of health policy work can be consulted about funding elements of an advocacy campaign or ongoing health advo- cacy work. Often coalition members, such as labor organizations, can contribute needed funds for a campaign.

Depending on the strategy you choose, you may need one or more individuals with special skills such as lawyers, experienced lobby- ists, webmasters, fund-raisers, campaign managers or media experts. Usually, one or more of the coalition members who have worked as advocates will have staff with these special skills. The strategy you decide on will depend, in part, on the resources you can count on for your campaign.

What Strategy and Which Place Where decisions Are Made Will you Use? Advocacy strategy starts with where the campaign will focus its efforts to change the rules; that is, which place where decisions are made will you choose to bring about change?

Advocacy strategy

starts with where the

campaign will focus

its efforts to change

the rules; that is, which

place where decisions

are made will you

choose to bring

about change?

Advocating for Change | Understanding How to Impact Health Policy 17

Advocacy Steps to Make change Happen

considerations in choosing a Place Where decisions Are Made After you have gathered together the facts and your analysis and a working coalition is in place with the resources you need, the next step is deciding whether to create public pressure, meet with government officials or take another course of action. One thing to consider is how much time the entire process will take. Can you act within the time people (the community, the media and government officials) expect to see action? Can you expect a decision within the time frame you think is reasonable?

You need to think about other issues as well: Is the coalition more com- fortable starting off by talking to the company or agency before creating public pressure? Is health at imminent risk requiring immediate strong action such as a public demonstration? Can you keep up with the work required to handle the follow-through steps, including presenting your facts and arguments at meetings and hearings in the capital, if legisla- tion is introduced? Will the coalition take a backseat to lawyers if you go to court? Will the coalition be perceived as weak if you don’t go to court?

In choosing a place where decisions are made, remember that you can decide later to include an additional place where decisions are made to increase pressure, maintain momentum, continue media and public interest, and enhance your organizing and coalition building. Success- ful campaigns often involve coordinated work in more than one place where decisions are made at a time. But it is essential that the work in different places where decisions are made be well-planned and coordi- nated so that scarce resources are efficiently used, decision makers are held accountable, and the campaign presents a focused and forceful presence.

➜ You can use Making a Plan: Developing Solutions on p. 65 of the Worksheets to guide your work.

➜ Information on Making a Plan can be found on p. 50 in References.

18 Advocating for Change | Understanding How to Impact Health Policy

Your campaign will

need to influence the

public and decision

makers. A just cause

can be more powerful

than mountains

of money and all

the political contacts

in the world.

coMMUnicAting yoUR MeSSAge— infoRMing tHe PUBlic And deciSion MAkeRS

Your campaign will need to influence the public and decision makers. A just cause can be more powerful than mountains of money and all the political contacts in the world. The challenge is to craft a way to communicate your concerns and goals so that they are understood and believed, and move people to take the action you seek. There are four foundations for successful communications.

1. You must offer accurate facts and respected analysis.

2. You must present a broadly acknowledged value.

3. You must tell a simple and compelling story.

4. You must reach the right audience.

Using accurate facts and respected analysis is important for the credibil- ity of your campaign. Your credibility will affect your ability to organize and build a coalition. It will also affect how you are viewed by the pub- lic, the media and decision makers. It will be harder to earn support if you exaggerate or omit essential facts.

A broadly acknowledged value is as direct as “lowering the number of fatal auto accidents” or “providing health care for everyone.” Everyone, of every viewpoint, will support an issue directly related to improving or maintaining health if it is clearly stated. There may be differences about whether the solution is feasible, affordable, adequate or fair, but your campaign will have the broadest possible support if the underly- ing cause is based on a broadly acknowledged value. Those who oppose your campaign will also be placed in the position of defending why they will not find a way to bring about better health.

Facts and values provide the foundation for telling a simple and compel- ling story. When you add in the real people and institutions that have been or may be harmed you complete the picture. Successful campaigns are built on and fueled by making a case that people can understand and relate to and want to see solved.

In reaching the right audience for your campaign, it is helpful to list the people who can improve the health issue you are focused on. Then decide what they each need to hear. Next, list the best means of having

Plain Facts

facts must be accurate but presented

in a way that creates understanding.

for example:

“ the center for Asthma Prevention

[hypothetical] has released a study

that shows:

• Air pollution from automobile

exhaust in Metropolis, california,

now averages xxx ppm.

• It has increased by x% over

the last year.

• Current levels are more than

double health standards set by

state government.

• Incidents of asthma in children

under 12 have doubled in the last

three years.

• The University Public Policy Center has

concluded a five-year study that shows

a direct link between air pollution and

asthma in children under 12.”

these are the types of facts that are

needed to convey the problem. these

facts begin to establish the broadly

acknowledged value that increased

asthma in children is undesirable and

to set the stage for telling a simple

and compelling story of the individual

children suffering a lifelong disease

that can be prevented.

Advocating for Change | Understanding How to Impact Health Policy 19

Advocacy Steps to Make change Happen

each audience hear the facts and the story that will move them to support your effort. Is your audience the public, opinion leaders, decision makers or potential allies? Do they need to understand the problem, or if there is gener- al agreement on the problem, do they need to understand a solution, why the solution will work and who supports it? And then, what is the best communication strategy? Is it the media, print, electronic, Internet, or is the best method personal meetings, group forums or perhaps a demonstration?

Keep in mind that the communication goal is not a 60-sec- ond evening news story or a meeting with an important official. You want more; you want to drive public support and decision-maker action to move your community’s health agenda forward.

key to Success — first establish the Problem Communication efforts should first concentrate on es- tablishing that there is a problem—what it is and who is being affected—before trying to encourage a particular solution. In some cases, those who are on the front lines of health, such as providers or health policy experts, do not realize that not everyone sees the problems they are confronting every day. Until a clear and convincing dem- onstration of the problem has been established, the public, the media and decision makers will not give credence to, or may even be confused by, a discussion of how to solve the problem. That is why telling a simple and compelling story is important; it establishes the problem in peoples’ minds and motivates them to find a solution.

If public opinion leaders, allies, the media and decision makers know about the problem, including who is being affected and how they are being affected, you have com- municated well. Try to ensure that each audience hears your message—first about the problem and then about the solution.

Building support means communicating with the public by talking to individuals, groups, opinion leaders and de- cision makers directly, as well as by using the media and

Saving Food

A good example of effective communication

was the fight to provide california consumers

with fresh, wholesome produce at the lowest

cost. california growers, agriculture co-ops and

the state department of Agriculture had spon-

sored the passage of statutes to keep prices for

fruit high by making it illegal to sell more than

the limits established each year, which were

based on the size of the crop. one year, when

a bumper crop of plums and other stone fruit

was predicted, consumer, senior and child ad-

vocates foresaw that thousands of tons of fruit

would be destroyed or left to rot because of

state laws.

the activists gathered facts that showed that

an enormous amount of fresh, edible fruit was

going to be wasted in order to keep prices

high. the groups also showed that an artifi-

cially limited supply of fruit would result in

substantially higher prices. informal surveys

found that people on low or moderate incomes

who wanted to buy fresh fruit for themselves

and their children would not be able to do so.

consumer, senior and child advocacy groups

then linked up with a few growers and retailers

who wanted to be able to sell all of the fruit

grown. Working together, they drafted and in-

troduced a bill that said, “nothing in law can

restrict the sale of fresh edible fruit.” this lan-

guage captured a widely held value and told

the story of the fight at the same time.

the four foundation stones of communication

were in place:

1. the facts: destroying good food would

keep prices high and deny consumers the

ability to buy and eat healthy fruit.

2. the accepted value: People should be able

to buy healthful, affordable food.

3. the story: An informal coalition of farm-

ers, retailers and consumers are working

together for this common good.

4. the right audience: the coalition

successfully communicated its message

to the public, which put pressure on

legislators to take action.

the next step is to present the campaign to

people who can help achieve the result you want.

the informal coalition of farmers, retailers and

consumer groups used the media, community

meetings, flyers, printed grocery bags and

person-to-person contact to communicate the

fruit problem. the agriculture industry and the

california department of Agriculture backed

down and the destruction of healthy fruit was

ended.

20 Advocating for Change | Understanding How to Impact Health Policy

Advocating for Change | Understanding How to Impact Health Policy 21

Advocacy Steps to Make change Happen

the Internet. Communication is reaching people with information to convince them to support your work for better health. The creation of tools such as fact sheets, background papers, question and answer handouts, and similar short documents is essential for communicating your issues. Developing these materials helps you decide how best to present the issues in different and effective ways. Once you have them, these materials can be used in all of your strategies for communica- tion. They can be used for door-to-door canvassing of neighborhoods, distributed to the media, put up on a Web site or handed out to elected officials.

talking with People A good deal of organizing and coalition building is done by getting the message out person-to-person, through house and block meetings, through door-to-door canvassing, by passing out information in front of supermarkets and at flea markets, and other ways of reaching indi- viduals. In some communities, church meetings, passing out or posting one-page flyers, talking to youth groups, or visiting senior centers are effective ways to reach people. One project to address domestic violence sent organizers to Laundromats to reach women in the community to find out their views, experiences and needs. It worked, and an effective program was developed.

There are many ways to reach out to educate and convince individuals that there is a problem they should care about. Think through who is likely to be affected by the problem and where you can meet and talk with them. You can build public awareness and personal involvement by talking to people as individuals. This kind of interaction allows you to learn what information helps people understand the issues and be- come convinced of the cause. You can learn what facts and arguments are important to people, which can help you develop ways to present your best case.

There are many

ways to reach out to

educate and convince

individuals that there

is a problem they

should care about.

22 Advocating for Change | Understanding How to Impact Health Policy

talking to opinion leaders and decision Makers Direct communication with opinion leaders and decision makers is a crucial means of building support for your position and getting people with the power to effect change to act on your behalf. An opinion leader can be a person respected and looked to for leadership by his or her community, such as the director of a local program, a local pastor, the president of the women’s committee or an elected official. These influ- ential people can take a leadership role in a community effort to work for better health. An opinion leader can be asked to help right from the beginning and may even be the right person to lead or be the spokes- person for the coalition. Such a person can give more visibility and importance to your coalition and can help convince others to join.

You also want to communicate with the decision makers, people who can take the policy action you need for bettering your community’s health. You need to find out who will influence or make the decisions on your issues. They may be government staff, corporate executives, hospital directors or personnel, elected officials or potential funders. Once you find out who the key people are, arrange to reach them di- rectly. When you communicate with decision makers you want to be prepared with facts, information and analysis and have a coalition or other strong support with you. Whether you arrange a lunch meeting, an office visit or a formal hearing, your presentation should be planned. You want to decide on:

> the purpose of the meeting

> the main points to discuss

> How to describe the problem clearly

> What papers or materials you will bring

> Who will lead your group during the meeting

> Who will speak, on what points and in what order

> What the group will ask for

When meeting with decision makers it is important to stick with the facts and not overstate the problem or use inflammatory rhetoric.

When you commu-

nicate with decision

makers you want to

be prepared with

facts, information

and analysis and

have a coalition or

other strong support

with you.

Advocating for Change | Understanding How to Impact Health Policy 23

Advocacy Steps to Make change Happen

Assume that once the decision maker is convinced of the seriousness of the issue and your sincerity in wanting to bring better health to your community, he or she will want to help solve the problem. Stra- tegic use of the media can help show opinion leaders and decision makers that you are working on an important issue that the public cares about.

the Role of the Media Coalitions use the news media to inform the public about their cam- paign and to mobilize support. In most cases, news stories come about because of hard work to reach and educate reporters and edi- tors. Getting free media, rather than buying an advertisement for your cause, enables you to reach a lot of people at once in a way that demonstrates that what you are working for is generally recognized as important. Elected officials, their staff, courts, government agency staff, leaders of nonprofit agencies and business leaders pay atten- tion to the news and to editorial commentary. The media—print and broadcast—have a major impact on public understanding of issues.

Will the Media Pay Attention? Media coverage is an essential ingredient for a successful health ad- vocacy campaign. Here are some questions to ask in order to predict whether you will get the media coverage you will need:

• Is this an interesting and important story showing verified evidence of serious problems that endanger individuals and community health?

• Are there credible spokespeople who can describe the problem and individuals who can talk about the impact on their health?

• Is the same problem continuing to happen? Has there been any news media coverage of the problem?

• Have there been similar health problems in other areas?

• How has the media covered other complaints about this issue?

The answers to all of these questions will help assess how much media coverage you can expect.

24 Advocating for Change | Understanding How to Impact Health Policy

common Ways to Reach the Media News Releases A news release tells the story of what is wrong, who says so and what should be done. News releases are usually no more than two pages and are a good way to keep reporters and editors up-to-date on the progress of the campaign and important events.

News Conferences At news conferences people supporting your position talk to reporters about the facts and analysis of the problem and the solution. The speak- ers have an opportunity to explain data, describe who is being hurt, and explain why the proposed solution will work. The purposes of the cam- paign can be laid out, members of the coalition can be introduced and reporters can ask questions. News conferences should be reserved for unusually significant events and complex subjects.

Reporters and Editors It is important to call and meet with the people who decide if your campaign is newsworthy and how it will be covered. These personal conversations give you a chance to find out what journalists think about what you are doing. It also gives you a chance to find out what others are saying about your campaign.

Editorial Writers You can try to get a newspaper or other media source to support your position publicly and urge the action you seek. Present your facts and reasoning either over the phone or in an editorial meeting.

Letter to the Editor You can respond to any related event by writing a short letter to the editor of a newspaper with your comment or viewpoint. This can be a reminder to the public and all concerned about your position and your sustained involvement in activities related to the issue.

Opinion Piece Newspapers and some radio and TV stations will carry a well thought out essay describing your issues. You need to contact the opinion editor to discuss what he or she is looking for, how long your piece can be and when it can be run.

opinion piece: newspapers and some radio and tv stations will carry a

well thought out essay describing your issues. you need to contact the

opinion editor to discuss what he or she is looking for, how long your

Advocating for Change | Understanding How to Impact Health Policy 25

Advocacy Steps to Make change Happen

the Role of the internet The Internet is an efficient and inexpensive way to reach the public, the media, and decision makers in government and corporations. Ad- ditionally, with a little extra effort, the Internet can be used for fund raising. The two main tools of Internet advocacy are e-mail and Web sites. You can use e-mail to educate and enlist new supporters to your campaign, to communicate with coalition members, and to com- municate with other campaign members by personal mail, listservs, discussion forums and action alerts.

A Web site can be a powerful tool for communicating: your campaign goals, plans, and identity; information on how to get involved, con- tact and contribute to the campaign; how and when to contact decision makers; and when to show up at meetings, rallies, and hearings. A Web site provides the media and policymakers initial access to your campaign and a way to follow up and contact you directly for more information.

The Internet enhances and expands your campaign’s communications, which are essential to health policy advocacy. It is not, however, a sub- stitute for the direct, personal contact needed to successfully organize, educate and persuade supporters, the media and decision makers. Re- member not to overuse e-mail by inundating your supporters and the media with an outpouring of nonessential information. You also need to be aware that IRS rules for nonprofit advocacy activities apply to the use of the Internet. For more guidance see E-Advocacy for Nonprofits: The Law of Lobbying and Election-Related Activity on the Net, published by Alliance for Justice. (For more on the Role of the Internet, see p. 52 in References.)

To be successful, your campaign must use every available method to tell the story of how existing conditions are hurting people and how the situation can be improved.

➜ You can use Communicating Your Message: Getting the Word Out on p. 70 of the Worksheets to guide your work.

➜ Information on Communicating Your Message can be found on p. 51 in References.

The Internet enhances

and expands your

campaign’s communi-

cations, which are

essential to health

policy advocacy.

26 Advocating for Change | Understanding How to Impact Health Policy

Advocacy Principles—Guidelines for Success Health policy advocacy builds on many skills you now have. Success requires creativity, hard work and perseverance. It can all be a bit easier if you keep this list of principles in front of you as you advocate for better health solutions.

Basic Personal Principles ➜

factual accuracy

total honesty

Responsible tone (keep inflammatory rhetoric in check)

Respect confidences

Basic Work Principles ➜

Work within a coalition

define the problem

Have a plan with defined interim goals and final goals

include community building

Be flexible about strategies

don’t humiliate opponent

Basic campaign Principles ➜

frame the issue—tell a story

Stay on the offensive

Raise the stakes

Stay on mission—don’t get sidetracked

no party politics

Basic Sustaining Principles ➜

Maintain perspective

Have 3 to 5 key advisers

Have a life

never think it’s over

never quit

Advocating for Change | Understanding How to Impact Health Policy 27

notes:

28 Advocating for Change | Understanding How to Impact Health Policy

Advocacy Places Where decisions Are Made3 Health policy decisions are made in many places by many individuals and institutions. They are made by elected and appointed officials who serve in local, state and federal governments. They are made by the courts and by people themselves through the ballot box. They are also made by private sector organizations such as health plans, hospitals and corporations. You must identify which decision maker can best address the problem you have identified.

cHAnging tHe lAW

A primary means of bringing about change is to try to persuade the state or federal legislature, local city council or county board of super- visors either to pass a new law or to change existing laws. For example, in 2001, consumer groups in California sponsored a law that required reporting on the outcome of coronary arterial bypass graft surgery and other procedures done in the state by naming the hospital and sur- geon for each procedure. The coalition was inspired by a similar rule in New York that had resulted in saving lives. The medical profession and others joined consumer groups, and the governor signed the bill in September of 2001. This new law will result in better quality health care and the better practice of medicine.

considerations Legislation must be carried by a politician trusted by the coalition to work in partnership to pass a new law that will really meet the com- munity’s health needs and not someone’s political agenda. The elected official who agrees to carry your legislation must be a person with the credibility, time, energy and staff to actually get the bill passed and signed into law. The coalition members must be careful to avoid becoming viewed as working with one political party or the other.

The elected official

who agrees to carry

your legislation must

be a person with the

credibility, time, energy

and staff to actually

get the bill passed and

signed into law.

Advocating for Change | Understanding How to Impact Health Policy 29

cHAnging tHe lAW

+ Pluses – Minuses

Legislators and local legislative officials are elected and, at least theoretically, accountable to voters.

Drafting and passing legisla- tion is a highly political process. Elected officials will weigh how their actions might help or hurt their standing with voters, campaign contributors and supporters.

In smaller communities, elected officials may be very accessible to members of the public.

The state legislature is in session for only part of the year. There are also deadlines for introduc- ing bills and for proposed bills to make their way through the legislative process.

Unlike the courts, the legislature can look beyond the law and broadly examine public policy.

Legislative rules typically make it easier to stop proposed laws or ordinances than to pass them.

A law enacted by the state leg- islature can address a problem in communities statewide.

Elected officials like to please everyone, which makes it more difficult to pass controversial legislation.

An ordinance adopted in one community can be a model for other communities. A new law enacted by the California Legis- lature can be a model for other states.

Sacramento (or Washington, D.C.) may be far enough from your community that it is difficult for community leaders and support- ers to meet with legislators and attend hearings in the capital.

➜ Information on Changing the Law can be found on p. 53 in References.

Advocacy Places Where decisions Are Made

30 Advocating for Change | Understanding How to Impact Health Policy

In trying to get a

government agency

to solve or prevent a

health problem, you are

relying on that agency

to be willing to support

your coalition’s analy-

sis of the problem and

what needs to be done.

WoRking WitH goveRnMent AgencieS

At the federal, state and local levels, there are government admin- istrative agencies (departments, commissions, boards, etc.) that are responsible for various aspects of the health care system. The details of a public policy are often determined by the regulations issued by a health agency after a law has passed.

Federal, state, regional and local agencies have the power to adopt, amend or repeal rules governing health care, safety and the environ- ment. They can also bring enforcement proceedings to stop actions that violate the law or agency rules and can even fine and revoke the licenses of violators. Agencies also have the power to investigate prob- lems and advise the executive branch (president, governor or mayor) and the legislature regarding the need for new laws, programs and oth- er governmental actions that would improve our health care system.

There are several ways to try to impact how an agency serves the health of your community. You may want to ask an elected representative to write or call an agency director and schedule a meeting, inviting the community coalition leaders to join, or the coalition may ask for a meeting directly. The coalition or an elected official may arrange a town hall meeting and invite the agency director to attend and partici- pate. You may also encourage a reporter to investigate and write a story on the problem your community has identified. A more formal way to encourage change is to file an administrative petition.

The California Government Code gives any person the right to file an administrative petition to a state agency requesting the adoption, amendment or repeal of a rule. The U.S. Constitution also gives people the right to petition any government agency for the redress of griev- ances. Advocates have used these rights to bring about important reforms in California. For example, Consumers Union and 24 other community organizations successfully petitioned the Department of Corporations to adopt rules regarding the conversion of nonprofit health maintenance organizations into for-profit entities, thereby establishing procedures to protect the interests of the public. (See the sidebar on p. 12 for more on this coalition’s success story.)

considerations In trying to get a government agency to solve or prevent a health problem, you are relying on that agency to be willing to support your coalition’s analysis of the problem and what needs to be done. In some

Advocating for Change | Understanding How to Impact Health Policy 31

cases, the community members may view the agency itself as “the problem.” Nonetheless, it is almost always a good idea to get your in- formation and analysis, gather your support, and talk to the decision makers in the agency. If you are not successful, you can then make the point that, “We tried to work with the agency, but they refused to pro- tect our community’s health needs. That is why we have come to the city council for action.”

WoRking WitH goveRnMent AgencieS

+ Pluses – Minuses

Since agencies typically have broad authority to act “in the public interest,” they can address actions that are harmful but not necessarily illegal.

Since agency heads are appointed by the executive branch and subject to oversight by the legislature, they are still subject to political pressure.

You can request agency action at any time, request immediate action in emergency situations, and address problems on a statewide basis.

In some instances, the legisla- tive branch may have expressly limited an agency’s power over a specific practice or type of entity.

Agencies can act relatively quickly (months, rather than the years sometimes required for a lawsuit or legislation).

Because of their backgrounds and experience, agency heads and staff members may be sympathetic with the industry or profession they are responsible for regulating. Depending on the issue, going di-

rectly to the decision maker may be less political than the legisla- tive or legal process. (In most cases, friendly legislators can still help your cause before the agency by voicing their support.)

Filing an administrative petition is a formal action that is taken seriously by agency officials and the media.

Community leaders do not have to be represented by lawyers.

➜ Information on Working with Government Agencies can be found on pp. 42 and 53 in References.

Advocacy Places Where decisions Are Made

32 Advocating for Change | Understanding How to Impact Health Policy

Health policy change

can take place in

hospitals or health

plans as well as in reg-

ulatory or accreditation

bodies or professional

organizations.

WoRking WitH HeAltH cARe inStitUtionS

Health care institutions set policies and practices in response to laws and regulations, but also independently. These policies can determine how health care institutions operate, and can include, for example, the quality and level of services provided or who has access to such services. Health policy change can take place in hospitals or health plans as well as in regulatory or accreditation bodies or professional organizations. Health care institutions can be part of the government (e.g., a county Department of Health Services) or they can be in the private sector. Private sector health care institutions can be nonprofit organizations—including providers (e.g., Kaiser), medical associations (e.g., California Medical Association), or regulatory bodies (e.g., Joint Commission on the Accreditation of Healthcare Organizations)—or for-profit enterprises, such as a health plan or pharmacy.

A health care institution’s goal is to improve health, primarily by pro- viding services to consumers. It may also seek to profit or serve a social or religious mission. If it is not serving the community, your job as an advocate is to show that it is not doing its job and how it could improve. Health care institutions are places where you can advocate for decision makers to directly implement better health solutions.

Whether the decision maker is responsible for a government health care provider or a private health institution, you need to take the same steps to make change happen. With facts, support, planning and communi- cation, these institutions can be persuaded to change their systems and improve your community’s health care. Because health care institutions can be either governmental bodies or private companies, be sure to read Working with Government Agencies and Working with Private Companies in this chapter when planning your campaign.

considerations Decision makers for health care institutions can be held accountable if they are not providing or improving health care consistent with their goal and mission. Some will welcome community involvement in identifying problems and working toward solutions. Others may be unhappy about being called to task for falling short. From their per- spective inside the institution they may feel that they are doing all they can with the resources they have or without making less profit. It is important to recognize the decision makers’ concerns, but advocates must represent the community’s perspective on the quality or degree of services being provided when advocating for change.

Advocating for Change | Understanding How to Impact Health Policy 33

For example, community health care advocates in Oregon prepared a report on the bill-collection practices of a local hospital, which included home foreclosure. Their report then compared the harassment of pa- tients who were too poor to pay their bills with the hospital’s claims of providing free and uncompensated care to the community. When the hospital’s decision makers were shown a copy of the report they agreed to change their policies, to provide real free and uncompensated care, and to cease harassing those too poor to pay for needed services.

Agreeing on and describing the health care problem, explaining how it is affecting community members, and then comparing the problem to the goal and mission of a health care institution can be an effective strategy for a campaign.

WoRking WitH HeAltH cARe inStitUtionS

+ Pluses – Minuses

Health care institutions’ stated goal of providing quality health services for a community pro- vides a lever to encourage policy change to better those services.

Decision makers can be very defensive and closed minded when told that their institution is failing to meet the communi- ty’s needs.

Documenting problems threatens to damage a health care insti- tution’s reputation, which can impel its decision makers to work with the community to reach solutions.

Community members may not be affected by the same prob- lems or they may be reluctant to challenge their local health care institution.

Many health care institutions want to maintain good commu- nity relations and are open to at least discussing problems experi- enced by community members.

Raising a serious problem may cause outside critics to suggest shutting down a facility rather than working to solve the problem.

Working with decision makers in health care institutions can lead to more open and continuing dis- cussions and better community health in the future.

Many local providers are part of a larger state or national chain, which may make them harder to influence.

Improving practices in one health care institution can lead other institutions to change.

Advocacy Places Where decisions Are Made

34 Advocating for Change | Understanding How to Impact Health Policy

WoRking WitH PRivAte coMPAnieS

Private businesses have an enormous stake in improving the delivery of health care in California. Many businesses either provide or would like to provide health insurance coverage for employees and their families. Other businesses, such as pharmaceutical manufacturers, managed care companies, hospitals and nursing home chains, provide the prod- ucts and services that make up our health care system. How they go about doing business is influenced by each company’s private policy decisions.

Working with private businesses to bring about change in their poli- cies may involve meeting one-on-one with executives or departments to help solve a particular problem (for example, making certain pre- scription drugs available at no charge to pediatricians in low-income neighborhoods). It may also involve urging businesses to be part of a larger alliance to reform the system itself through new laws, rules, structural changes or incentives.

The Environmental Defense Fund (EDF) worked with McDonald’s to reduce the use of antibiotics to enhance the growth of beef and chicken. After lengthy discussions and negotiations, McDonald’s entered into an agreement with EDF to not purchase chicken or beef produced with growth enhancing antibiotics. That decision has meant the farm- ers have had to change how they raise animals if they want to sell to McDonald’s. By working with business, EDF brought about a policy change that could benefit the health of millions of people.

considerations Working with business will almost always result in less than what the community thinks is the best way to solve its health problem. Keep in mind that a solution proposed by a company may not be ideal from the community point of view, but it must be at least a good part of what is needed to improve or maintain health or the coalition will challenge the company to do better. Some groups and individuals may still be un- comfortable working with corporations they view as “the bad guy,” and they may criticize the coalition. But with sufficient outside pressure, including pressure from critics of the coalition’s efforts, private com- panies can be convinced that it is in their business interest to change their policies.

Working with private

businesses to bring

about change in their

policies may involve

meeting one-on-one

with executives or

departments to help

solve a particular

problem.

Advocating for Change | Understanding How to Impact Health Policy 35

WoRking WitH PRivAte coMPAnieS

+ Pluses – Minuses

Since its public image is a very valuable asset, a business may be especially willing to help address a specific problem if it enhances its image among consumers, shareholders, employees, govern- ment officials and/or the media.

Every business is a for-profit entity. Typically, businesses will oppose proposals that might harm their economic interests, support proposals that further their economic interests, and be indifferent to proposals that do not affect those interests.

Large corporations have consid- erable resources that could be enormously helpful in bringing about change (money of course, but also media and public rela- tions resources, lobbying and governmental affairs staffs, and high level contacts with other large businesses, foundations and government).

Businesses will want public credit for working with com- munity groups, sometimes even when they are doing little or nothing to address community concerns. (Simply meeting with community groups, for instance, could be inflated by a corporate public relations department into “working closely with [your organization] to attack [your problem] in [your neighborhood].”)

Support from businesses (both large corporations and small companies) may increase the credibility of your proposal and lead to wider political support.

Many businesses have little or no experience working with community groups and may initially be hostile, suspicious or slow to understand how their interests overlap with those of the community.Change by a large corporation

can have an effect on its many suppliers by forcing them to provide better products.

Getting one corporation to change can set standards for others to meet.

➜ Information on Working with Private Companies can be found on p. 53 in References.

Advocacy Places Where decisions Are Made

36 Advocating for Change | Understanding How to Impact Health Policy

USing tHe BAllot Box: tHe initiAtive And RefeRendUM PRoceSS

The California Constitution gives voters the power to adopt new laws by initiative and repeal existing laws by referendum. The charters of many local governments also provide for direct lawmaking by voters through the initiative and referendum process.

Health care and consumer activists have used the initiative process to pass measures that have been blocked in the regular legislative pro- cess. For example, health advocates in California successfully passed a tobacco tax proposal that repeatedly failed in the state legislature.

Like any proposed law, an initiative measure needs to be carefully draft- ed to achieve the result you are seeking and, if possible, avoid problems for opponents to attack. In most cases, sponsors of an initiative need to collect a minimum number of signatures to have the proposal put on the ballot, and at least 51 percent of the voters who show up to the polls must vote “Yes” for it to pass.

considerations Passing a ballot measure requires significant time and energy. For the last six weeks of a campaign it’s a flat-out effort that can feel over- whelming, as well as exhilarating. Working on an initiative is a very public process where everything and every group are subject to scru- tiny by the media and the public. The leadership and the members of the coalition must be prepared to have their actions subject to intense public review.

Health care and

consumer activists

have used the initiative

process to pass mea-

sures that have been

blocked in the regular

legislative process.

Advocating for Change | Understanding How to Impact Health Policy 37

USing tHe BAllot Box

+ Pluses – Minuses

The initiative process can circumvent the regular legisla- tive process and tap into public outrage about a problem.

Huge amounts of time and money can be expended to qualify and pass an initiative.

Some initiatives (typically on social issues) do not draw any opposition or require a huge expenditure of money.

Often voters are not sympathetic to complicated measures, spend- ing additional tax dollars or passing new laws.

If passed, an initiative can have lasting impact (e.g., Proposition 13 on property taxes, Proposition 98 on school funding, Proposition 103 on insurance regulation).

If a proposal could harm a major economic interest, expect strong, well-financed opposition.

➜ Information on Using the Ballot Box can be found on p. 54 in References.

USing tHe coURtS

One method of bringing about change is to file a lawsuit. When legisla- tive and administrative actions were blocked by the powerful tobacco industry, lawsuits finally helped to bring about important reforms.

In a lawsuit, the plaintiff must do more than simply argue that what the defendant is doing is wrong or harmful. A lawsuit contends that the defendant is violating constitutional, statutory or common law.

Typically, lawsuits are brought either to stop actions that violate exist- ing law(s) or to require actions that are mandated by existing law(s). On occasion, when an appellate court interprets existing law in a new way, a lawsuit can result in changing how the law is applied.

considerations Keep in mind that there are situations when community members may feel that taking the matter to court is necessary to show that the community is strong and forcefully pursuing its rights. There are also situations when the decision maker may agree, but because of political considerations wants the courts to force her or him to take the right

A lawsuit contends

that the defendant

is violating constitu-

tional, statutory or

common law.

Advocacy Places Where decisions Are Made

38 Advocating for Change | Understanding How to Impact Health Policy

action. When a government agency or private corporation is sued, it generally feels that it has been attacked. Litigation can cause the people you want to make decisions to become angry and refuse to talk to you. It is wise to try other approaches before going to court.

USing tHe coURtS

+ Pluses – Minuses

A lawsuit can be filed on any business day of the year.

It is difficult for courts to address matters of pure policy— for example, finding the best way to solve a health problem.

Plaintiffs can ask for emergency orders or injunctions to prevent “irreparable harm.”

Unless sufficient funding is avail- able, going to court requires a lawyer who is willing to work pro bono or for a contingent or reduced fee.

Courts may be less overtly politi- cal than other venues. (However, depending on the state, judges may be elected or appointed by elected officials.)

Once a suit is filed, the focus tends to shift to the court and the lawyers, making it harder for members of the community to be involved.

A lawsuit can result in an impor- tant legal precedent that leads to reforms in other areas.

A well-funded defendant can use tactics that drive up costs in an effort to exhaust a plaintiff’s funds.

In some types of cases, there is the potential for recovering attorney’s fees and litigation costs.

Lawsuits can take quite a long time—sometimes years—espe- cially if appeals are involved.

➜ Information on Using the Courts can be found on p. 54 in References.

Advocating for Change | Understanding How to Impact Health Policy 39

diRect gRoUP Action

In some cases it may be necessary to take direct group action to focus public attention on an issue. For example, if filing a lawsuit, going to the legislature or filing an administrative petition is not feasible, you might explore whether a respected local institution (e.g., League of Women Voters, PTA, newspaper, community clinic, church or union) would sponsor a public hearing on the issue. Ideally, the sponsoring institution would work closely with community leaders to schedule the hearing; invite speakers, elected officials, policymakers and the media; plan the agenda; and actually convene and chair the hearings.

considerations The success of taking direct group action will often be judged by the number of people who turn out, the importance of the participants and the general seriousness of the event. You are asking the media and the public to pay attention to your event, so a good deal of planning and organizing is essential to present your best possible case. Some may as- sume that you are holding your own event because you have no other support. You will need to focus on the fact that you are not relying on others and have the strength and creativity to bring your community’s health issues in front of the public and decision makers.

diRect gRoUP Action

+ Pluses – Minuses

Community leaders will have input into many aspects of the event, including subject matter, how issues will be presented and who will be invited.

Scheduling a hearing and invit- ing people to attend is easy. Actually getting them to pre- pare, attend and participate in a manner that will result in an effective event requires exten- sive one-on-one effort.

A carefully planned and well- orchestrated event can educate government officials, local politi- cians, reporters and the wider public about your particular problem.

Direct group action is not an end in itself but sets the stage for other actions to bring about change, including legislation, litigation, petitioning admin- istrative agencies and working with private businesses.

The success of taking

direct group action

will often be judged

by the number of

people who turn out,

the importance of the

participants and the

general seriousness

of the event.

Advocacy Places Where decisions Are Made

40 Advocating for Change | Understanding How to Impact Health Policy

diRect gRoUP Action cont.

+ Pluses – Minuses

Public officials can be called on for their views. They may be given the opportunity to tell those attending the hearing or other event what action (if any) they plan to take to address the problem.

The logistics can be daunting: Community leaders and the sponsoring institution will have to decide where and when to hold the hearing or other event; whether the facility can safely accommodate the number of people expected; what the tone should be; who should be invited to attend and speak; who should chair the event; how the event should be opened; who should speak, in what order and for how long; how to control speakers who try to dominate or divert the hearing or other event.

Organizing a public event can utilize community resources and build the community’s capacity to advocate for its health needs.

➜ Information on Direct Group Action can be found under Health Care Advocacy on p. 45 in References.

No matter where you decide is the best place to advocate or which decision maker you decide is the best to help solve the problem you have identified, you will need to take certain follow-up steps to fully implement your strategy.

➜ You can use the Worksheets starting with After You Take Action on p. 76 to help organize your work and carry out your campaign successfully.

Advocating for Change | Understanding How to Impact Health Policy 41

Advocacy Places Where decisions Are Made

The Health Advocacy Process

StePS to MAke cHAnge HAPPen

Getting the Facts—Research and Data Collection

Building Support—Organizing and Coalition Building

Making a Plan—Develop Goals and Strategies

Communicating Your Message—Informing the Public and Decision Makers

iMPleMent yoUR PlAn

Advocacy Places Where decisions Are Made

Advocacy Process to impact decision Makers

Changing the Law Working with Government Agencies

Working with Health Care Institutions

Working with Private Companies

Using the Ballot Box

Using the Courts

Taking Direct Group Action

Define Problem

Collect Information

Inform Media

Organize Support

Talk to Decision Makers

oUtcoMe

Action granted Action denied Celebrate

Follow Up

Media

Implementation

Monitor

Protect Win

Follow Up

Coalition Planning & Decision Making

Media

Public Education

Monitor

Evaluate Next Course of Action

42 Advocating for Change | Understanding How to Impact Health Policy

government Sources – federal

Bureau of Primary Health Care U.S. Department of Health and Human Services www.dhhs.gov Government information regarding health care policies including resources, databases and documents.

Centers for Medicare and Medicaid Services www.cms.hhs.gov Federal agency responsible for administering Medicare, Medicaid, SCHIP (State Children’s Health Insurance), HIPAA (Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments), and several other health-related programs.

Council on Private Sector Initiatives (CPSI) to Improve the Security, Safety, and Quality of Health Care: Agency Representatives and Contacts. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality www.cpsi.ahrq.gov/contacts.htm List of government representatives and contacts useful for advocacy work.

Office of Minority Health U.S. Department of Health and Human Services www.omhrc.gov The Office of Minority Health improves and protects the health of racial and ethnic minority populations through the development of health policies and programs that will eliminate health disparities.

References4

43

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government Sources – State

Legislative Analyst Office www.lao.ca.gov Known for its fiscal and programmatic expertise and nonpartisan analyses of California’s state budget, the Analyst’s Office has been providing fiscal and policy advice to the legislature for more than 55 years.

Legislative and Governmental Affairs California Department of Health Services www.dhs.ca.gov/lga/index.htm Government information and resources to facilitate, coordinate and advocate for legislation in the interest of public health.

Office of the Patient Advocate Department of Managed Health Care, State of California www.opa.ca.gov Information to assist health care consumers, includes policy briefs, reports and educational sources.

Office of the Secretary California Health and Human Services (CHHS) www.chhs.ca.gov Official site of CHHS with information on state and federal programs for health care, social services, public assistance and more.

Statutes and Regulations Relating to Health Care Plans in California, Department of Managed Health Care www.hmohelp.ca.gov/library/regulations Information on codes, legislation and acts regarding the regulation of health plans in California.

Advocating for Change | Understanding How to Impact Health Policy

44 Advocating for Change | Understanding How to Impact Health Policy

foundations

Blue Shield of California Foundation www.blueshieldcafoundation.org Statewide foundation committed to making health care effective, safe and accessible for all Californians, particularly underserved people, and to ending domestic violence.

The California Endowment www.calendow.org/about/frm_about.htm A private, statewide health foundation providing grants to community- based organizations in California.

California Health Care Foundation www.chcf.org Health foundation providing information to inform health policy decisions, improve quality of health care and fund programs that meet its goals.

The California Wellness Foundation www.tcwf.org The foundation makes grants for health promotion, wellness education and disease prevention.

Henry J. Kaiser Family Foundation www.kff.org The foundation conducts extensive policy and data analysis on health issues in California and nationwide.

Robert Wood Johnson Foundation www.rwjf.org The foundation seeks to improve the health and health care of all Americans.

45Advocating for Change | Understanding How to Impact Health Policy

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Health care Advocacy

The Advocacy Institute www.advocacy.org The Advocacy Institute is dedicated to strengthening the capacity of social justice advocates and movements to influence and change public policy.

Advocacy: Oh Yes, You Can …, Nonprofit Quarterly www.nonprofitquarterly.org/section/155.html This issue (Volume 7, Issue 2, December 2000) focuses on advocacy for nonprofits. Included are articles on framing social policy and lobbying and advocating without fear.

Alliance for Justice: The Nonprofit Advocacy Project www.allianceforjustice.org/nonprofit/index.html Works to strengthen the voice of the nonprofit sector in public policy debates by giving tax-exempt organizations a better understanding of the laws that govern their participation in the policy process.

The CAN Advocacy Center http://givevoice.org/canonprofits/home.html The California Association of Nonprofits has joined with national organizations Independent Sector and the National Council of Nonprofit Associations to provide an easy-to-use forum, called GiveVoice, for nonprofit leaders, staff members, volunteers and supporters to impact public policy.

Center for Community Change www.communitychange.org The center helps low-income people, especially people of color, build powerful, effective organizations through which they can change their communities and public policies for the better.

Charity Lobbying in the Public Interest www.clpi.org This Web site is a public resource for nonprofit organizations to learn about the powerful contributions to society that can come from lobby- ing in the public interest.

46 Advocating for Change | Understanding How to Impact Health Policy

The Democracy Center www.democracyctr.org Dedicated to strengthening the advocacy work of nonprofit and com- munity groups in California, the center provides advocacy training, counseling, strategy planning and other assistance.

The Lobbying and Advocacy Handbook for Nonprofit Organizations Amherst H. Wilder Foundation www.fieldstonealliance.org This guide will help you understand your role in shaping public policy, assess the benefits of lobbying to fulfill your mission, and show you how to develop and carry out an advocacy plan.

NPAction.org www.npaction.org This online resource is designed to support capacity building for non- profit advocacy by collecting the best practices of seasoned advocates and engaging newcomers with a wide range of topics and tools.

OMB Watch: So You Want to Make A Difference: Advocacy is the Key www.npaction.org/article/archive/194 This advocacy manual provides resources to help local leaders and citizens learn and feel more confident about getting involved in policy advocacy.

Real Clout: A How-To Manual for Community Activists www.realclout.org/ppi/publications/RealCloutTextbook.stm Real Clout addresses issues such as how to convince state or county public officials to interpret existing laws and regulations differently, as well as how to work with a state or county public official to design, create and fund a new program.

47Advocating for Change | Understanding How to Impact Health Policy

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Academic

Center for Health Services Research and Policy George Washington University www.gwhealthpolicy.org/chsrp The Center provides policymakers, public health officials, health care administrators and advocates with the information and ideas they need to improve access to quality, affordable health care.

Central Valley Health Policy Institute California State University, Fresno www.csufresno.edu/ccchhs/HPI/bottomfr.html The Institute facilitates an interactive regional process to identify, moni- tor and analyze emerging health policy issues that influence the health status of people living in Central California.

Health Policy Institute, Georgetown University www.georgetown.edu/research/ihcrp Health policy and services research group at Georgetown, site includes publications and links to its studies.

Nicholas C. Petris Center, School of Public Health University of California, Berkeley 2150 Shattuck Avenue, Suite 525, Berkeley, CA 94720-7380 (510) 643-4100, Fax (510) 643-4281 www.petris.org “The Center helps to guide public policy by creating the data and conducting the research needed to understand today’s complex health care market. It provides up-to-date information on changes in the health care system that may impact the health care marketplace and alter its capacity to provide high-quality care at competitive prices.”

UCLA Center for Health Policy Research University of California, Los Angeles www.healthpolicy.ucla.edu Health policies and policy research especially relating to access to care and health coverage, health promotion and disease prevention, and public programs and finance, particularly within California.

48 Advocating for Change | Understanding How to Impact Health Policy

AdvocAcy StePS to MAke cHAnge HAPPen

getting the facts

Bardach, Eugene. The Eight-Step Path of Policy Analysis. Berkeley Academic Press, 1996.

The Budget Process: A Citizen’s Guide to Participation. Senate Select Committee on Citizen Participation in Government, 1996.

California Health Interview Survey (CHIS) UCLA Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute www.chis.ucla.edu CHIS is an important source of information on health and access to health care services. Its telephone survey of adults, adolescents and children from all parts of the state is conducted every two years.

Data Center: Impact Research for Social Justice www.datacenter.org

E-The People www.e-thepeople.com

Federal and State FOI Resources and Guides. The Freedom of Infor- mation Center. School of Journalism, University of Missouri. foi.Missouri.edu/laws.html.

The Freedom of Information Act: A User’s Guide. Washington, D.C., Freedom of Information Clearinghouse, 1997. www.citizen.org/litigation/free_info/articles.cfm?ID=5208.

Hane, Paula J. Super Searchers in the News: The Online Secrets of Journalists and News Researchers. Medford, NJ. CyberAge Books, 2000.

Health DATA Program UCLA Center for Health Policy Research www.healthpolicy.ucla.edu/HealthData/index.html A major public service program of the UCLA Center for Health Policy Research, their goal is to build the capacity of advocates, organiza- tions and coalitions to use health research data to address public health policy issues important to the communities they serve.

49Advocating for Change | Understanding How to Impact Health Policy

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E S

The Health Policy Guide www.healthpolicyguide.org Provides evidence-based, peer-reviewed policy guidance and resources to support advocacy and decision making at the state and local levels.

Safir, Adam. State Profile of California. Urban Institute, 2004.

US Blue Pages www.usbluepages.gov “Your online guide to the U.S. Government.”

Building Support

Activist Center for Training In Organizing and Networking www.actionpa.org

Bobo, Kim, Jackie Kendall, and Steve Max. Organizing for Social Change. Seven Locks Press, 2001.

Center for Community Change www.communitychange.org

Center for Third World Organizing www.ctwo.org

Community Building Tools Community Toolbox, University of Kansas http://ctb.ku.edu/tools

Kahn, Si. How People Get Power. (revised) NASW Press, 1994.

50 Advocating for Change | Understanding How to Impact Health Policy

Making a Plan

California’s Emerging Health Care Advocate: You!. Citizens for the Right to Know and the California Medical Association. www.rtk.org/resources/health.pdf. Guide for advocates of health care consumer rights, including defini- tions, resources and hints for efficiency.

Cancer Clinical Trials: A Resource Guide for Outreach, Education, and Advocacy. National Cancer Institute, 2002. www.cancer.gov/clinicaltrials/resources/outreach-education-advocacy/ page1. Published in Adobe with information to help individuals and organiza- tions participate in and engage communities in outreach and education activities. Includes resources such as worksheets and a Plan for Action for advocates.

The Democracy Center. Strategy Development: Key Questions for Developing an Advocacy Strategy. www.democracyctr.org/resources/strategy.html.

Loue, Sana, Linda S. Lloyd, and Daniel O’Shea. Community Health Advocacy. Kluwer Academic/Plenum Publishers, 2003.

Making your Advocacy Efforts Count. Health Education Advocacy Organization. www.healtheducationadvocate.org. Action alerts and health care advocacy tips.

Public Policy Grantmaking Toolbox. Northern California Grantmakers. www.ncg.org/toolkit/home.html.

Schultz, Jim. The Democracy Owners’ Manual. Rutgers University Press, 2002.

51Advocating for Change | Understanding How to Impact Health Policy

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communicating your Message

Berkeley Media Studies Group www.bmsg.org

Connecticut Health Policy Project www.cthealthpolicy.org/toolbox

Frameworks Institute www.frameworksinstitute.org

Media Advocacy Manual. American Public Health Association. www.apha.org/news/Media_Advocacy_Manual.pdf. Manual outlining ways advocacy groups can effectively use radio, television and print media.

Public Media Center www.publicmediacenter.org

Saasta, Timothy. How to Tell and Sell your Story Part I: A Guide to Media for Community Groups and How to Tell and Sell your Story Part II: A Guide to Developing Effective Messages and Good Stories about your Work. Center for Community Change, 1998.

Salzman, Jason. Making the News: a Guide for Nonprofits and Activists. Westview Press, 1998.

Wallack, Lawrence, Lori Dorfman, David Jernigan, and Makani Themba. Media Advocacy and Public Health. Sage Publications, 1993.

52 Advocating for Change | Understanding How to Impact Health Policy

Using the internet

Benton Foundation 950 18th Street N.W., Washington, D.C., 20006 (202) 638-5770, Fax (202) 638-5771 [email protected], www.benton.org

Bimber, Bruce A. Information and American Democracy: Technology In the Evolution of Political Power. Cambridge University Press, 2003.

Bimber, Bruce A. Campaigning Online: The Internet in U.S. Elections. Oxford University Press, 2003.

Browning, Graeme. Electronic Democracy: Using the Internet to Transform American Politics. (2nd ed.) Medford, NJ. CyberAge Books, 2002.

The Civic Web: Online Politics and Democratic Values. Eds. Ander- son, David M., and Michael Cornfield. Rowman & Littlefield, 2003.

Davis, Steve, Larry Elin, and Grant Reeher. Click on Democracy: The Internet’s Power to Change Political Apathy into Civic Action. Westview Press, 2002.

Kingsley, Elizabeth, Gail Harmon, John Pomeranz, and Kay Guinane. E-Advocacy for Nonprofits: The Law of Lobbying and Election- Related Activity on the Net. Alliance for Justice, 2000.

Net Action 601 Van Ness Avenue, #631, San Francisco, CA 94102 (415) 775-8674, Fax (415) 673-3813 [email protected], www.netaction.org

53Advocating for Change | Understanding How to Impact Health Policy

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AdvocAcy PlAceS WHeRe deciSionS ARe MAde

changing the law

The Legislative Process: A Citizen’s Guide to Participation. Senate Select Committee on Citizen Participation in Government, 1996.

Harmon, Gail, Jessica Ladd, and Eleanor A. Evans. Being a Player: A Guide to IRS Lobbying Regulations for Advocacy Charities. Alliance for Justice, 1995.

Kent, Dierdre. The Joy of Lobbying. Gateway Lobbyskills. Wellington, New Zealand, 1998.

Working with government Agencies

Snyder, Harry, Carl Oshiro, and Ruth Holton. Getting Action: How to Petition Government and Get Results. 2002. www.consumersunion.org/other/g-action1.htm. A guide for health care advocates to work successfully with government sources.

Working with Private companies

Corporate Accountability Project www.corporations.org/research.html

Couey, Anna. Hands-On Corporate Research Guide. CorpWatch. www.corpwatch.org/research/PRD.jsp?articleid=945.

Endgame Research Services A Project of the Public Information Network www.endgame.org

Environmental Defense Fund Alliance For Environmental Innovation www.environmentaldefense.org Provides concrete examples of partnering with businesses and sample forms for working with businesses.

54 Advocating for Change | Understanding How to Impact Health Policy

Using the Ballot Box

Ballot Initiative Strategy Center 1025 Connecticut Ave. N.W., Suite 205, Washington, D.C., 20036 (202) 223-2374, Fax (202) 289-1530 www.ballot.org

California Secretary of State Initiative Update www.ss.ca.gov/elections/elections_initiatives.htm

Initiative & Referendum Institute 1825 I Street N.W., Suite 400, Washington, D.C., 20006 (202) 429-5539, Fax (202) 986-3001 [email protected], www.iandrinstitute.org

The Public Charity’s Guide to the California Initiative Process. Northern California Grantmakers. www.ncg.org/assets/NCGpubliccharityguide.pdf.

Shultz, Jim. The Initiative Cookbook: Recipes and Stories from California’s Ballot Wars. The Democracy Center/Advocacy Institute West, 1996.

Using the courts

American Bar Association www.abanet.org/legalservices Consumer’s guide to legal help on the Internet.

55Advocating for Change | Understanding How to Impact Health Policy

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notes:

notes:

Advocating for Change | Understanding How to Impact Health Policy56

57

The Worksheets outline tasks that will help to organize your research, writing, decision making and actions. Your answers will provide a convenient summary of your findings and strategy, and will form the basis for your plan.

1. getting tHe fActS 58

1a. Researching the Problem 58

1b. Research Findings 60

2. BUilding SUPPoRt: inviting otHeRS to Join 62

3. MAking A PlAn: develoPing SolUtionS 65

4. coMMUnicAting yoUR MeSSAge: getting tHe WoRd oUt 70

4a. Reaching Your Audience 70

4b. Using the Media to Reach Your Audience 72

5. AfteR yoU tAke Action 76

6. if yoUR iSSUe iS ScHedUled foR A Meeting oR HeARing 77

6a. Find Out What Format the Meeting or Hearing Will Take 77

6b. Prepare for Your Meeting or Hearing 77

6c. Marshal Support 79

6d. Post Meeting or Hearing Comments 80

7. if yoUR SolUtion iS AdoPted 82

8. if yoUR SolUtion iS denied 83

5Worksheets W

O R

K S

H E

E T

S

Advocating for Change | Understanding How to Impact Health Policy

58 Advocating for Change | Understanding How to Impact Health Policy

1. getting the facts

1a. Researching the Problem

1. The following people are being hurt by the current situation:

a.

Because

b.

Because

c.

Because

2. The people listed in No. 1 are able/unable to protect themselves because:

3. This is a serious problem because:

59Advocating for Change | Understanding How to Impact Health Policy

W O

R K

S H

E E

T S

1. getting the facts

4. The following people and organizations are benefiting from the current situation:

a.

Because

b.

Because

c.

Because

5. How widespread is the problem?

6. If left unattended, the problem is likely to get worse/stay the same/get better because:

7. What has been done elsewhere to solve the problem?

60 Advocating for Change | Understanding How to Impact Health Policy

1b. Research findings

Note: Using credible sources (including information from community organizations as well as individ- uals, books, the Internet, government documents, databases and academic sources) is essential when getting the facts. Proper referencing is also important to build the case for why action should be taken.

Key facts about the problem:

a.

Reference source

b.

Reference source

1. getting the facts

61Advocating for Change | Understanding How to Impact Health Policy

W O

R K

S H

E E

T S

c.

Reference source

d.

Reference source

1. getting the facts

62 Advocating for Change | Understanding How to Impact Health Policy

1. The following people/groups are likely to be interested in supporting your advocacy efforts:

a.

Because

b.

Because

c.

Because

d.

Because

e.

Because

2. Building Support: inviting others to Join

Advocating for Change | Understanding How to Impact Health Policy

W O

R K

S H

E E

T S

2. Building Support: inviting others to Join

2. The person(s) who will be responsible for contacting the above and asking for their support is:

Name Date Will Contact By

a.

b.

c.

d.

e.

3. What do people/groups think about the problem as you describe it?

a.

b.

c.

d.

e.

63

64 Advocating for Change | Understanding How to Impact Health Policy

2. Building Support: inviting others to Join

4. What do they think should be done?

a.

b.

c.

d.

e.

5. Will they join in your efforts?

a. d.

b. e.

c.

65Advocating for Change | Understanding How to Impact Health Policy

W O

R K

S H

E E

T S

3. Making a Plan: developing Solutions

1. What is the issue/problem?

2. What do you want changed?

3. Who can fix it?

4. What are possible solutions?

The decision makers could solve or alleviate the problem by:

a. Prohibiting people from:

1.

2.

3.

4.

b. Permitting people to:

1.

2.

3.

4.

66 Advocating for Change | Understanding How to Impact Health Policy

c. Requiring people to:

1.

2.

3.

4.

d. Taking disciplinary action against:

1.

2.

3.

4.

e. Holding hearings on or open an investigation on:

1.

2.

3.

4.

f. Performing the following services:

1.

2.

3.

4.

g. Taking the following actions:

1.

2.

3.

4.

3. Making a Plan: developing Solutions

67Advocating for Change | Understanding How to Impact Health Policy

W O

R K

S H

E E

T S

5. What are your three most desirable solutions?

a.

b.

c.

6. Who else agrees with you or supports you?

7. Who opposes you?

8. What is the plan? Clearly state:

a. Interim goals to achieve your policy solution

3. Making a Plan: developing Solutions

68 Advocating for Change | Understanding How to Impact Health Policy

b. Tasks and timeline to accomplish interim goals

c. Partners you will work with in coalition

d. Available resources, including:

1. funds

2. personnel

3. Making a Plan: developing Solutions

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3. office space and support

e. How your plan will build the capacity of your community to advocate for policy change

9. Which place(s) where decisions are made (health care institutions, government agencies, legislature, ballot box, private companies, and courts) will you use to achieve your policy goal?

10. Is there a role for direct group action in your plan?

3. Making a Plan: developing Solutions

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4a. Reaching your Audience

1. You need to reach the following people because they are affected by the problem and need to be aware of the issues and what can be done:

a.

b.

c.

d.

e.

f.

g.

2. Who are the decision makers who need to take the action you want?

a.

b.

c.

d.

3. You also need to reach the following audiences/people because they are likely to be influential in persuading decision makers:

a.

b.

c.

d.

e.

4. communicating your Message: getting the Word out

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4. In this case, a broadly accepted value that will persuade this audience to take the action you recommend is:

5. What facts should be emphasized to your audience?

6. What is a simple and compelling story that can describe your broadly accepted value and the facts you have identified?

4. communicating your Message: getting the Word out

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4b. Using the Media to Reach your Audience

1. The media that will reach your audience are (identify the target audience for each media contact):

a. Newspapers (daily, weekly, student, foreign language, neighborhood, etc.):

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

b. Radio stations (network, local, foreign language, university, public, etc.):

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

4. communicating your Message: getting the Word out

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c. Television stations (network, local, cable, foreign language, public, etc.):

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

d. Magazines (weekly, monthly, specialty):

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

4. communicating your Message: getting the Word out

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e. Wire services:

1.

2.

3.

4.

5.

f. Other (community organizations and church newsletters):

1.

2.

3.

2. Rank the previous media outlets in order of importance/effectiveness in reaching your audience.

Newspapers

Radio stations

Television stations

Magazines

Wire services

3. Your media contact person will be:

4. communicating your Message: getting the Word out

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4. The story/case/study/problem(s) you will emphasize when communicating with the media is (are):

a.

b.

c.

5. To explain the issue to reporters you will use (check one or more):

News release

News conference

Other

6. You will issue your news release/hold your news conference

on

at a.m./p.m.

Note: The information collected on your worksheet is the basis of your news release or press conference. Keep the worksheet before you as you plan. Periodically review the worksheet to ensure that you have not forgotten anything.

4. communicating your Message: getting the Word out

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1. The person responsible for keeping in touch with individuals in the place where decisions are made is:

2. You will also monitor the decision maker’s action by:

3. The person who is responsible for keeping your coalition and supporters up-to-date on the progress of your action is:

4. The person who is responsible for keeping the media up-to-date is:

5. After you take Action

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6a. find out What format the Meeting or Hearing Will take

1. The arrangements are satisfactory/unsatisfactory because:

2. If the arrangements are unsatisfactory, the actions you should take are:

a.

b.

c.

d.

6b. Prepare for your Meeting or Hearing

1. In preparing your presentation you should:

a. Bolster the following points:

1.

2.

3.

4.

5.

6.

6. if your issue is Scheduled for a Meeting or Hearing

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b. Present the following changes in the facts, law or government policy since your last public statements:

1.

2.

3.

4.

5.

c. Respond to opposing arguments as follows:

Opposing argument

Your response

Opposing argument

Your response

Opposing argument

Your response

Note: The information collected on your worksheet is the basis of your presentation.

6. if your issue is Scheduled for a Meeting or Hearing

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2. At the presentation, advocates on your side will be:

Advocates Presenting on

a.

b.

c.

3. Your media contact person will be:

4. The person responsible for taking notes and obtaining copies of the meeting or hearing testimony is:

6c. Marshal Support

1. You will ask the following people/groups to support your effort by testifying at or attending the meeting or hearing, or by sending a letter of support:

a.

b.

c.

d.

e.

f.

g.

h.

2. The person(s) responsible for contacting the above people/groups is (are):

6. if your issue is Scheduled for a Meeting or Hearing

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6d. Post Meeting or Hearing comments

1. The arguments raised in opposition are:

a.

b.

c.

d.

2. They are defective because:

a.

b.

c.

6. if your issue is Scheduled for a Meeting or Hearing

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d.

3. Recent developments adding to your case are:

a.

b.

c.

d.

4. Items you promised to supply the decision maker are:

a.

b.

c.

d.

6. if your issue is Scheduled for a Meeting or Hearing

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1. List the actions that must be taken before the decision becomes effective:

a.

b.

c.

d.

e.

2. You will issue a news release/hold a news conference

on

at a.m./p.m.

3. This decision will solve/alleviate the original problem by:

4. To solve the entire problem, you should:

5. You will express appreciation by:

7. if your Solution is Adopted

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You should/should not try again in your chosen place where decisions are made because:

8. if your Solution is denied

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