Universal Single-Payer Ballot Campaign in California
Paul Krehbiel, Labor United for Universal Healthcare, Los Angeles, March 6, 2014
The idea for Proposition 186 developed out of Health Access, a statewide healthcare consumer advocacy coalition, formed in 1987, advocating for quality, affordable care for all Californians. I got involved with Health Access in 1988 as the representative from the United Electrical workers (UE) in District 10 (California). By 1990, there were about 200 member organizations in the coalition.
Health Access focused on immediate realizable reforms in our health care system, but also studied comprehensive healthcare systems. The group determined that a single-payer system was superior on every major count, including providing universal coverage, high quality, and lower cost. Health Access worked with Democratic State Senator Nick Petris who introduced a single-payer bill in the state legislature in 1992. It garnered considerable support, but did not pass.
In January 1993 three organizations in the Health Access coalition, (California Physicians Alliance, California Congress of Seniors, and Neighbor-to-Neighbor) formed a committee to draft a single-payer health care initiative to be considered for placement on the November 1994 California ballot. The initiative was modeled on the Petris bill. When the committee’s initiative was complete, it was presented to the Health Access board for approval to go onto the November 1994 ballot. After considerable discussion, a majority of the Health Access board voted not to put the initiative on the ballot in 1994, fearing it would lose by a considerable margin, and urged that more education and base building be done prior to launching a ballot campaign.
Divisions from the Beginning
Members of the Health Access single-payer committee decided to establish another organization, called Californians for Health Security, to launch a drive to put the initiative on the November 1994 ballot. Both Neighbor-to-Neighbor, and the California Physicians Alliance had very small memberships in California; the California Congress of Seniors had approximately 500,000 members statewide.
There was some hope for optimism. Polls showed that a slight majority of Americans agreed when asked if they favored a health care system that covered everyone. Also, health care reform was at the top of the news in 1994 because President Bill and Hillary Clinton had launched a national campaign for health care reform, and while it was not a single-payer plan, it did capture much national and local publicity. Some within the single-payer group in California believed that a single-payer initiative here could get increased attention since the Clinton’s had put health care reform on the national agenda.
I mention this history because it shaped the development of the Proposition 186 campaign in a number of important ways.
First, the campaign was launched by a small group from the single-payer health care reform movement, while the majority of single-payer supporters felt the time was not ripe for such an initiative. I agreed with the majority sentiment, but along with many others, I joined the Proposition 186 campaign because we felt it was an important opportunity to do broad education for single-payer health care, and to build ties with organizations that favored a single-payer system.
Since the inner leadership core of the Proposition 186 campaign did not include many of the large constituent organizations that are essential to making such a campaign viable, the strategy was limited in many ways. Other larger organizations did join the campaign, and a small number played an important role. The campaign launched a major push to collect 615,958 valid signatures of registered voters (the number of signatures, set by law, must total 8% of all of the total gubernatorial candidates votes in the previous election.) That meant collecting one million signatures to allow for signatures that would be disqualified.
The response by single-payer supporters was impressive. Large numbers of volunteer supporters collected a substantial number of signatures, and along with paid signature gatherers, over 1 million signatures were turned in within the window period. The initiative qualified for the November 1994 ballot. That was a good start. However, the campaign had spent $600,000 of the approximately $812,000 raised between December 1993 and June 1994 to collect the required signatures, leaving little money for the campaign.
The Campaign then turned its focus to the center piece of its grass roots strategy: to hold house parties across the state to talk to neighbors and friends about supporting Proposition 186 in the intimacy of one’s home. The idea was that people who attended these house parties would be among the most dedicated and knowledgeable advocates for Proposition 186, and that they in turn would organize more house parties, and move the people they were in contact with to vote for Proposition 186. Supporters were also asked to talk to the leaders of major organizations to get their endorsement, and hopefully a commitment to donate money and resources to work on the campaign. Getting other organizations to endorse the campaign was very successful; over 500 organizations endorsed the Proposition 186 campaign. Aside from a few organizations who gave significant amounts of money and volunteer campaign workers, the large majority of organizations that endorsed Proposition 186 played a limited role or did little to build the campaign. The campaign also set up a fund-raising committee to finance the campaign and the media buys needed to get our message out to millions of voters.
After several months of house parties, it was clear that the campaign would reach only a small fraction of the 4.5 million votes it needed to win in November. By the end of the campaign there had been almost 1,500 house parties, which raised $750,000. With an attendance of approximately 25 people at each house party (though a number were smaller), it’s possible that the campaign talked directly to 37,500 people (the most optimistic figure). The hope was that those who attended a house party would talk to their friends, thereby multiplying the number of people who heard directly a “vote yes on Proposition 186” message. If we count only the number of people talked to directly at a house party, it would take 120 years to talk directly to 4.5 million voters at a house party. The campaign did talk to leaders of large mass membership organizations, primarily for endorsements and support, but for a variety of reasons (lack of time, lack of prior education, etc.) this did not yield the results needed. House parties can help, but they can’t be the major strategy for a campaign of this magnitude.
Organizing Large Organizations
As the campaign unfolded, a group in Los Angeles and in other parts of the state advocated a much more focused outreach to targeted voters by reaching voters through mass membership organizations. This group advocated working with the leadership of major large organizations to develop a comprehensive plan to help them reach their members. Two large constituencies named were organized labor, and senior organizations. In 1994, there were approximately 2 million union members in California, and approximately 3 million members of senior organizations. Together, that totaled 5 million people. This was a good start. But not enough.
While the universe of union members and members of senior organizations totaled 5 million people, not all union members nor all seniors are registered to vote, some don’t vote, and some will not vote the way their organizations recommend. The “Yes” votes among members of these groups would be less than the 4.5 million votes needed. Therefore, we also needed to have selected a number of additional large organized constituent groups to reach 4.5 million “Yes” votes well before Election Day. The “Yes” campaign did target large organizations that have high credibility among the voters. Among the highest in public credibility was the League of Women Voters, which endorsed Proposition 186. Another group with high public credibility is nurses. Our total targeted universe should have been 8 million likely “Yes” voters or more to build a buffer since some, perhaps a significant number, of “yes” votes would be lost when the opposition launched their “No” campaign.
We needed to approach this campaign like a union organizing campaign. We needed to have lined up enough solid “Yes” votes to win long before the voting took place. That meant (1) convincing leaders of large membership organizations that single-payer health care is what we all need, and (2) convince them to help develop a long-term educational and organizational campaign among their members. This would entail answering all of the questions, statements, and arguments by the opposition to inoculate our targeted universe of “Yes” voters so that anything the opposition would say would not deter our “Yes” voters from voting “Yes” on election day. (See the “Yes” campaign handout, “Proposition 186: Q&A. Everything you need to know to get the benefits you’re already paying for,” as an example of the questions that need to be answered for our targeted universe well before election day. Also, the quality of the answers must be absolutely convincing. While some of the answers presented in this Q&A handout were good, others needed improvement.)
In the proposition 186 campaign there was not enough time to do this. All of this should have been done in the year or two before the campaign. There is also the question regarding the ability to convince enough leaders of mass membership organizations that single-payer was superior and realizable, and that they should commit to advocating a single-payer system to help reach our targeted universe of voters. Many had already committed themselves to the Clinton health plan. The Clinton plan, however, was getting pounded nationwide by the insurance industry-led opposition, creating animosity among voters toward any government involvement in health care.
We also needed to take into account the political differences in various regions of California. The initiators of the Proposition 186 campaign came from the San Francisco Bay area. From their experiences, a large percentage of the population there favored single-payer. But that is a relatively small portion of the state’s entire electorate. Other areas that would likely generate some considerable support for single-payer would be Los Angeles, other large cities, and some of the coastal areas, but it would take much hard work to achieve majority support for single-payer in those areas. The rest of the state is more moderate to conservative politically, so we must win some level of support from these later areas in order to win. The liberal cities and coastal areas alone are not enough.
The Campaign Begins
The Proposition 186 campaign central message was that a “Yes” vote for Proposition 186 would achieve a health care system that is secure, that covers everyone all the time (regardless of job loss, change of job, or any other event), with better care, and at a lower cost.
The opposition (mainly insurance companies, as well as hospitals, other businesses, and conservative to right-wing organizations), used polling data that showed a widespread distrust of government and taxes (messages that the American people had been hammered with since the election of Reagan in 1980) to frame their campaign. They formed the organization “Taxpayers Against the Government Takeover” to drive their “No on Proposition 186” campaign.
They began by working to influence the wording of the draft language for the official California voter’s election and ballot pamphlet. Polling showed the opposition that many people were nervous about a radical change in the health care system, fearing negative consequences of a new and unknown system. The opposition convinced the Attorney General to change the description of Proposition 186 prior to printing to say that the single-payer system advocated by Proposition 186 would replace existing health insurance programs. Also, while a minority of voters had significant complaints with their existing health insurance plans, most did not.
The “Yes” campaign emphasized that Proposition 186 would cut down administrative expenses, preserve people’s choice of doctor and hospital, break the increasing power of the insurance industry to determine the care people get. The “No” campaign emphasized that Proposition 186 was too radical, would not control costs and would cost more (thereby requiring raising taxes), would mandate that the government would determine what kind of care people received and not your doctor, that the new proposed system would lead to delays and even rationing of care, and hamper technological innovation in medicine. However, the centerpiece of the “No” campaign, based on the voter concerns that polled the strongest, was to fuel the voters fear of “big” government “taking over” and making the health care system much worse.
Prior to public campaign advertising, support for and opposition to Proposition 186 was roughly divided, with a large percentage of likely voters undecided. Polls also showed that voters didn’t know much about Proposition 186.
The Media Campaign
In mid-August, the “No” campaign launched its media campaign with television and radio ads, mailings, and other media. By the end of September, the “No” campaign had raised $5.7 million and had blanketed the state with ads. One poll estimated that the “No” campaign had reached 96% of the state, and this was before the “Yes” campaign began our media campaign, according to a Kaiser/Harvard study. Polling then showed that the “No” vote was going up. The “Yes” campaign did not start radio and TV ads until mid-October due to lack of money, and the constraints of building and running the campaign in such a short time-frame.
Our “Yes” campaign was raising money to run media ads, since most of what had been raised was spent during the signature gathering phase of the campaign. The majority of voters heard only the “No’ campaign messages for two months until the “Yes” ads began to run.
Here’s one of the first TV ads by the “No” campaign:
A nurse says: “Believe me, we know health reform is critical.” (The nurse’s name and RN identity appeared on the screen). She continues: “But Proposition 186 isn’t the reform we need. 186 will force most of us to give up our private health coverage and push us into a government run health bureaucracy controlled by an elected politician, not a doctor or nurse.”
Then a document appeared on the screen identified as a “Government Election” handbook, with text on the screen that read” “Government Health Takeover. Source: CA Ballot Pamphlet.”
The ad didn’t tell voters that those words were not in the official description of Proposition 186, but were the words of an opponent who wrote in the “arguments against” section of the ballot pamphlet.
This is what millions of voters saw and heard before they ever heard anything from our “Yes” campaign. Messages like this went on for two months unanswered. During this time the “No” vote increased in the polls, and the “Yes” vote fell.
In July of 1994, after the ballot description had been changed in the final Ballot Pamphlet in response to the “No” campaign’s appeal, the “No” votes, according to polling, went up to 59%, and the “Yes” vote was at 31%.
In September, when the “No” campaign TV ads began, the “No” vote remained at 59%, while the “Yes” vote dropped 9 points to 22%.
On October 13, 1994, with continuing “No” ads running on TV and radio, the “No” vote went up to 62%. The “Yes” campaign, without TV ads yet, made some headway due to our grassroots organizing, but only increasing slightly to 23%, according to polling done then.
Our “Yes” campaign TV ads then began, but with less than a month before election day. On October 27, “Yes” campaign TV ads were being seen by millions (and so were the “No” campaign ads), and the “No” vote dropped to 58% and the “Yes” vote rose to 26%. Our “Yes” TV and radio ads and ground campaign was having some positive effect, yet we had a huge gap to close with less than two weeks until the election. More undecided’s were making up their minds, and some switching between “Yes” and “No” votes was taking place, based on the campaigns of both sides.
The “No” campaign spent over $9 million ($5.4 million came from the insurance industry), with over $4 million spent on media ads ($3 million on TV and $1 million on radio), and over $1.2 million in direct mailings to individuals in organizations in the “No” coalition. The “No” campaign outspent the “Yes” campaign in paid media by 4-1 ($4 million to $898,555), according to the Kaiser/Harvard study. (“The Single-Payer Debate: The Defeat of Proposition 186.”)
The “Yes” campaign spent about $1.5 million; the Los Angeles Times reported $2.5 million with ten days left in the campaign (10-29-94). These numbers must be checked for both campaigns.
Finally, the “No” ads appeared many more times than did the “Yes” ads and were selectively placed during popular TV programs to be seen by the maximum number of viewers.
On election night, another poll revealed broad opposition to new taxes, which the “No” campaign had been hammering on, showing 67% of likely voters favoring cuts to major spending programs rather than raising taxes (supported by just 10%), according to the Kaiser/Harvard study,
Proposition 186 lost by 73%-27%.
Start early and build the broadest coalition possible, one that will ensure massive outreach to millions of voters, develop a comprehensive grass-roots campaign, and insure the capacity to raise the millions of dollars needed to compete with the opposition.
Develop a campaign to target a winning universe of likely “Yes” voters. (See Health Care Action newspaper, October 1994, to see the breadth of large organizations that we needed to have worked with for a year prior to the campaign, but didn’t. A winning voter base must include organized labor, seniors, students and youth, people of color, women, social justice movements, and small businesses. Today, a ballot campaign will need 6.5 million votes to win in California, and should target 10 million likely “Yes” voters. This targeted group must be worked with for at least a year prior to the election to educate them to the advantages of single-payer (improved Medicare for All is a good way to frame it), and to inoculate them from all the arguments the opposition will make. (See the 4-page hand-out titled “Proposition 186: Q&A. Everything you need to know to get the health benefits you’re already paying for.” This handout asked 21 questions raised by our opposition and individuals trying to learn more about single-payer health care, and provided answers to each one. We needed to have been campaigning on these questions and answers to our targeted universe of likely “Yes” voters for a year before the campaign.) While our printed literature was important, it reached a small number of voters.
Message. We must develop a message that meets the needs of a significant majority of the voters, and answers all the questions that voters may have. Polling, surveys, and focus groups can help shape that message, and we must be relentless in spreading it to our universe of voters and beyond. We need to begin that process now. Some of our literature needed to be better, as noted above. We need to reassure voters that this is not a radical change into the unknown, but rather building on and improving a system that voters know and support, like Medicare. Medicare for All, or Improved Medicare for All is the kind of message framing that we should look closely at.
We must win the election well before election day as a massive onslaught of TV ads, lies and other tactics by our opposition will erode our “Yes” vote. The insurance industry and their allies spent a relatively small amount of money in order to defeat Proposition 186. They will spend many times more in a campaign that shows a chance of winning.
We need a top-flight professional election campaign team to run the campaign with our input and direction. This must include doing regular polling well before the election campaign and during it, to learn what likely voters are thinking, and to tailor our message to address their needs and concerns, while making and publicizing very convincing arguments as to why the current system is a threat to their wellbeing, and why Medicare for All is far superior.
The Proposition 186 campaign gave single-payer much larger exposure, educated many people about its benefits, and helped connect us with key organizations and constituencies that will be needed to achieve single-payer health care. It fostered the founding of Health Care for All – California and other groups, and increased work in other organizations for single-payer health care.Published April 7th, 2017
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