Szjp advocacy plan 12.3.17 (1) (1)

Senate Bill 562
Single-Payer Health Care in California
Advocacy Plan

Jonathan Palisoc & Sonya Zhu
Public Health 220D | Fall 2017

Sonya Zhu & Jonathan Palisoc Public Health 220D | Tony Iton & Harry Snyder
I. The Issue
A. Background

Fig. 1 - California single-payer history.
California’s most recent population estimates have approximated that over 40 million
individuals currently reside in the state. Of those 40 million individuals, over 93% are currently
insured; an estimated 40% of the population receives health insurance through the public sector (i.e.,
Medicare, Medicaid, or CHIP) while the other estimated 50% utilizes the private market (i.e., small
and large group, employer-based, or the individual marketplace also known as Covered California). 1
While California boasts an impressively low uninsured rate, the future of the state’s health insurance
coverage is at risk. Many of California’s gains in coverage have been recent, due to the Patient
Protection and Affordable Care Act (ACA). Yet since the November 2016 national election,
Republican lawmakers and the Trump administration have revamped their efforts to dismantle the
ACA. If the current federal government succeeds in eliminating some or all of the ACA, the years of
progress in health insurance coverage and health outcomes will be undone, such that the health and
financial security of Californians are severely threatened.
Before the ACA, the state’s uninsured rate was close to 20%. Many low-income Californians 2
and undocumented individuals were left with no option for coverage other than limited-scope
Medi-Cal (i.e., Emergency room, or ER visits) or limited coverage indigent programs (i.e., state
funded, county run programs that provided minimal health services to extremely low-income
individuals and some undocumented individuals). After expansion of the Medicaid program to
childless adults, implementation of the Covered California exchange, and covering undocumented
children with the passage of SB 75, the state was able to aggressively reduce the rate to an all-time low. 3
Besides California’s rapid growth in coverage, the state has been fairly effective in containing
costs. The state has a lower per-capita cost than the national average, although it has narrowed in
1
http://www.dhcs.ca.gov/formsandpubs/publications/opa/Pages/factsheet.aspx
2
http://www.chcf.org/publications/2017/11/californias-uninsured
3
http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/sb-75.aspx
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recent years. The state has also been a hotbed of innovation for payment reforms such as 4
pay-for-performance and other incentive or value-based payments. This, however, does not exempt
California from cost problems that are deeply rooted in the US. Along these issues: Medicaid rates
have been criticized as being so low that they discourage physician participation, and many Health 5
Maintenance Organizations (HMOs) operating in the state have been criticized as having immense
reserves and margins on some populations.
Again, this is consistent with the United States as a whole – compared to other developed
countries, the US has consistently ranked around the highest in health care costs. Criticisms of the
system have been exacerbated by low marks on quality of the system, in health outcomes and patient
satisfaction. While the reasons behind high prices and low quality have been debated, many
government agencies and consulting firms have conducted reports to delve deeper into the issue. In
2007, McKinsey & Company conducted an analysis that is still widely cited today; it found that the
largest cost disparities in the US compared to other nations were due to (1) outpatient costs, (2)
pharmaceutical costs, and (3) administrative costs. 6
While outpatient costs have decreased significantly due to the increased prevalence of managed
care and upstream care, drug and administrative costs have continued to plague the system.
Proponents of health reform often point to single-payer when these issues are brought up; single-payer
systems boast low administrative costs due to a simpler system and low drug costs due to increased
government bargaining power.
There have been significant efforts to implement single-payer in California in the past 35 years.
In 1994, proponents successfully got single-payer listed as a ballot measure, but it was soundly defeated
due to a significant monetary advantage by the opposition . Health insurance companies created 7
numerous media ads that swayed the public with threats of increased government bureaucracy in
health care. In the early 2000’s, the California Health and Human Services Agency, in conjunction
with consultants from Lewin and the AZA group, built a report that proposed nine possible future
moves for California’s health system . Along those were universal coverage and single-payer options; 8
they found that single payer would result in expanded coverage and modest cost savings. Shield 9
Kuehl, a California state senator, used those reports to construct a single-payer bill in the Legislature.
Although it was passed twice during the 2000’s, Governor Arnold Schwarzenegger vetoed the bill
4
https://www.kff.org/other/state-indicator/health-spending-per-capita/
5
http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/09/22/are-medicaids-payment-rates-so-low-the
yre-discriminatory
6
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/accounting-for-the-cost-of-us-health
-care
7
https://www.kff.org/health-costs/report/the-california-single-payer-debate-the-defeat/
8
https://pdfs.semanticscholar.org/d210/6a9bd7f751a48489e1aad9c1c6aaad9fbfa0.pdf
9
To note, while universal health care coverage and single-payer health insurance are often used interchangeably, the two are
different concepts. Universal coverage is a broad umbrella term for various health policy options that ensure access to
health care for all. Single-payer falls under universal coverage, but refers specifically to a system in which a single public
entity oversees health care financing while mostly private entities provide health care; it is also known as “Medicare for all.”
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twice, citing cost concerns. Since then and up until the introduction of SB 562 this year, single-payer
efforts have taken a backseat to the defense of the ACA.
The Healthy California Act, SB 562, recognizes that all residents of the state of California have
the right to health care. Although the ACA expanded health care coverage for Californians, many
residents of the state remain uninsured or lack sufficient coverage. Introduced by State Senators Toni
Atkins and Ricardo Lara in February 2017, and co-authored by 14 other state lawmakers, SB 562
would establish comprehensive universal single-payer health care coverage in California and a health
care cost control system through the Healthy California (HC) program. Residents of California
would receive coverage for a wide variety of medical benefits and services, and would not be required
to pay any premium, copayment, coinsurance, deductible, or other form of cost sharing for covered
benefits. SB 562 aims to address the rise in health care expenditures and to ensure all Californians are
able to exercise their right to health care. 10
The Healthy California Act passed in the Senate in June 2017; however, later that month,
Assembly Speaker Anthony Rendon shelved SB 562 and prevented it from moving forward to a
hearing in the Assembly, citing several concerns over the bill regarding its incompleteness. A major 11
critique of SB 562 from the Speaker, as well as other state lawmakers, was its lack of detail on how
California would finance single-payer health care. While Rendon blocked SB 562, he later announced
in August that the Assembly Select Committee on Health Care Delivery Systems and Universal
Coverage would hold hearings to explore and discuss universal health care coverage in California. 12
B. Why We Selected the Issue
Given the repeated efforts of the Trump Administration and Congressional Republicans to
repeal and replace the ACA, some states have taken it upon themselves to push back and promote a
progressive health care agenda. Under the Congressional Republicans’ health care bills, , millions of
Americans would lose their insurance. ,
For California, the state would have much to lose if federal 13 14
lawmakers overhauled the ACA, as many Californians are currently covered under the program. ,
15 16
While Congress did not end up successfully repealing and replacing the ACA in 2017, from an
advocate and activist standpoint, time is limited; the iron is hot and must be struck soon due to
increased interest in the issue. By capitalizing on resistance to the efforts of the Trump
Administration, a coalition has a serious opportunity to gain significant funding and traction from the
public. Thus, SB 562 is a critical piece of legislation that would protect and continue to promote the
health of Californians.
10
https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201720180SB562 2
11
http://www.latimes.com/politics/la-pol-sac-single-payer-shelved-20170623-story.html
12
http://www.latimes.com/politics/essential/la-pol-ca-essential-politics-updates-assembly-speaker-anthony-rendon-
who-1503598991-htmlstory.html
13
https://www.cbo.gov/publication/52752
14
https://www.cbo.gov/publication/52849
15
http://www.pnhp.org/sites/default/files/HR676vsACAvsAHCA.pdf
16
http://www.sacbee.com/news/local/health-and-medicine/article148703944.html
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C. Proposed Solution
Although the push for single-payer will likely carry on in some form, it is essential that
advocates of SB 562 in California continue to be deliberate and strategic in their efforts moving
forward. Given that SB 562 was blocked in the Assembly, and that opportunities exist to delineate and
discuss the components of SB 562 in Assembly hearings, the next step for the bill is to undergo
revision or to be introduced as a completely new bill and pass the Legislature. In accordance with plans
for a modified or new bill, the advocacy strategy will identify sources of funding for the campaign,
address the fiscal and implementation concerns revamp communications (i.e., framing, messaging,
narratives) to better connect with diverse stakeholders, and build a broad-based coalition unlike prior
single-payer coalitions. This plan outlines how advocates can bolster efforts to bring single-payer to
fruition e through a comprehensive, coordinated advocacy campaign.Broadly stated, the goal of the
campaign is: By the end of the 2018 legislative session, advocates will demonstrate the value of
single-payer to gain broad-based public and political support, and to enable the passage of a revised or
new version of SB 562, ensuring that all Californians have access to comprehensive, affordable health
care.
The objectives are as follows:
a) Campaign Operational Objectives
i. Acquire grants from state health foundations and other sources of funding.
ii. Build an effective, broad-based coalition.
iii. Change the narrative around single-payer from being perceived as high-cost and increased
bureaucracy, to a more humanistic, pragmatic program.
iv. Neutralize opponents through campaigning on a well-tested framing and messaging (e.g.,
cost-effectiveness, California as a leader in the nation), including a “poem” of a bill.
b) Legislative Objectives
i. Convince previously opposed legislators of the benefits and feasibility of single-payer health care.
ii. Pass a revised version of SB 562 or a new bill by the end of the 2018 legislative session.
iii. Governor signs the single-payer bill into law.

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II. Campaign Elements
For sake of structure, the elements of the plan will be broken into two main components:
Pre-bill introduction and post-bill introduction.

Fig. 2 - Pre- and post-bill introduction sequencing.
A. Pre-Bill Introduction
1. Selecting a Forum
California represents the largest population in the US, accounting for 12% of total population
and over 40 million individuals. Of those 40 million individuals, over 1⁄3 of them receive health
coverage through Medi-Cal, the state-run Medicaid program. Including the more than 1.5 million
individuals gaining health insurance through Covered California, around 16 million individuals
receive some type of insurance through (or heavily subsidized by) the government.
Currently, the overwhelming bulk of those not insured through Medi-Cal, the exchanges, or
employer-based insurance are the undocumented. Although efforts have been made during recent
years (e.g., SB 4) to expand coverage to the undocumented, the only success has been expansion to
undocumented children in SB 75. Moreover, previous state legislative efforts for single-payer have
stalled (e.g., ColoradoCare, VT’s Green Mountain Care, CA’s Healthy California),
Nevertheless, we feel that the California Legislature is the most pragmatic and suitable forum
for single-payer. The Legislature has the power to pass universal coverage, as outlined by the rules of
Title XIX of the Social Security Act. Executive orders, rules changes, or legal changes due to judicial
lawsuits are not feasible paths, and ballot initiatives have been largely unsuccessful (see Prop 186,
1994). State departments concerned with health care may also be tapped into as a complementary
forum. These include the California Health and Human Services Agency (e.g., the Department for
Health Care Services, Department of Public Health, and Department of Managed Health Care) and
the California Department of Insurance.

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2. Funding
From previous failures, it has become increasingly evident that California coalitions pushing
single-payer have been woefully underfunded compared to their opponents. As such, the first order of
business for the advocacy campaign should be to secure funding for future efforts. To do this, the
largest California foundations (i.e., The California Endowment, California Health Care Foundation,
California Health and Wellness Foundation, Blue Shield of California Foundation) should be
approached to help fund the effort.

Fig. 3 - California’s “Big Four” Foundations.
A small, core coalition should be leveraged to approach the foundations. This coalition would
be comprised of well-known, knowledgeable, pragmatic and idealistic advocates of universal coverage
in California, and who also have existing relationships with the boards of the foundations. Individuals
from influential health advocacy organizations such as Physicians for a National Health Program
(PNHP), California OneCare, Health Access, and California Nurses Association (CNA) would be
part of the contingent. This step is already in progress, with some individuals from these organizations
currently talking to the major foundations. 17
As part of this core coalition, messaging towards the foundations should appeal to their core
mission. Take for example, the California Endowment’s mission statement:
“The California Endowment’s mission is to expand access to affordable, quality health care for
underserved individuals and communities and to promote fundamental improvements in the health
status of all Californians.”
By emphasizing that single-payer in California hits at the core of these principles, the coalition
should provide a compelling argument for funding. Alongside the mission statement, current funding
efforts should also be noted; funding that is currently put towards Covered California outreach could
be redirected to single-payer efforts.
17
Based on interviews with Andrew McGuire and Henry Abrons
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In concrete terms, a starting ask for the foundations should be in the range of 10% of their
total grants. In dollar terms, this is around $25 million – the same amount that is currently being used
to fund Exchange advertising and other ACA efforts. Despite this being a significant ask of the
foundations, a large request now and negotiation down is better than a small initial ask. By appealing
to the mission, reasoning with the budget, and pushing the incredible importance of this funding to
the effort, we hope to gain a significant grant from the four major foundations.
3. Polling and Focus Groups
Once funding is secured, a significant amount of dollars should be spent polling the general
public and holding focus groups on single-payer. Health advocacy efforts in the past have been most
successful when an eloquent “poem” that captures the essence of an issue is constructed. By creating a
pleasing, palatable frame and message, grassroots efforts can convince the public (including the media
and Legislature) that single-payer is the correct way forward.
For polling, polls should be conducted to find the current level of support for single-payer.
Smaller polls have indicated that there is large approval of universal coverage; by expanding to
California as a whole, positive polling for single-payer can be used as a rebuttal when the opposition
tries to paint single-payer as negative and unpopular.
Current framing has been of health care as a right. Using focus groups, we wish to expand the
possible set of frames and corresponding messages to connect with voters of varying sociodemographic
groups and interests. For example, the concept that no Californian should go bankrupt due to health 18
care costs may appeal not only to people who agree that health care is a human right (typically liberals
and progressives), but also to fiscal conservatives. Moreover, a poem will be constructed that best fits
the advocacy campaign. This poem will likely be along the same lines as the successful poem of “Every
child has a right to education.”
4. Policy and Economic Analysis
Perhaps the most effective critique of SB 562 has been its cost. Early rough estimates of the bill
have estimated the cost of single-payer in California to be anywhere from $200-400 billion. While
these numbers have little basis in fact, proponents of SB 562 have been unable to effectively counter
these arguments. To alleviate this issue, a “New Lewin” analysis should be conducted.
18
More example frames and messages are presented in the Communications section of this plan.
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Fig. 4 - Updating the California Health Options Project (CHOP) report.
Contracting with knowledgeable consultants, a comprehensive report should be produced
that lays out a tailored framework, cost analysis, bill skeleton, and implementation plan for a
single-payer program in California. This report should be conducted using consultants and
economists who are viewed as nonpartisan and/or moderate; if the campaign relies solely on analysis
from left-leaning organizations (regardless of its analytical rigor), the opposition will seize upon this
fact to try and discredit the report.
Once the report is complete, it should be distributed internally within the Select Committee
for members to collaborate on strategy and decide on how to best use the report. As of November
2017, the Committee has met twice; although these meetings have been largely informational, the
Committee members have made it clear that they are looking for a solid report and plan that is tailored
to California. While it is premature to select a consultant now, the Commonwealth Fund would be a
strong candidate. 19
5. Building Support
The main coalition of SB 562 supporters is known as Healthy California and will continue to 20
be a part of advocacy efforts moving forward. Healthy California currently represents over 350 entities
and individuals across state and local government, healthcare, labor, community-based organizations,
faith-based organizations, businesses, and political entities.
19
The Commonwealth Fund may be perceived as left-leaning in general, but it operates as a nonpartisan organization.
20
http://www.healthycaliforniaact.org/
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Fig. 5 - Proposed coalition member groups.
a) Coalition members include but are not limited to:
● State Senator co-authors: Cathleen Galgiani, Scott Wiener, Benjamin Allen, Mike McGuire,
Nancy Skinner
● State Assembly Member co-authors: Rob Bonta, Jimmy Gomez, David Chiu, Laura
Friedman, Ash Kalra, Kevin McCarty, Adrin Nazarian, Mark Stone, Tony Thurmond
● State government: Dave Jones (CA Insurance Commissioner), Gavin Newsom (CA
Lieutenant Governor, 2018 CA Gubernatorial Candidate; informal supporter)
● Local government: City of Los Angeles, City and County of San Francisco, County of Santa
Clara, Oakland City Council, Marin County Board of Supervisors, Richmond City Council
● Health care: Physicians for a National Health Program (PNHP, CA Chapter), California
OneCare, Health Care for All
● Labor: CA Nurses Association (CNA), CA Labor Federation, CA Teachers Association,
Service Employees International Union
● Community: CA Pan-Ethnic Health Network, CA Youth Empowerment Network,
Greenlining Institute
● Business: American Sustainable Business Council, Patagonia, The CA Healthy Nail Salon
Collaborative, The Cheeseboard Collective
● Political: Local chapters of Democratic Club, Democratic Socialists of America, & Green
Party
● Faith: CA Church IMPACT, Clergy & Laity United for Economic Justice
● Affiliate campaigns: Campaign for a Healthy California, AllCare Alliance, Labor United for
Universal Healthcare, Business Alliance for a Healthy California
In addition to the above partners, we want to build out our coalition to include a broader community.
We need to engage powerful groups and individuals who may not have previously identified with this
issue, including:
b) Current groups and individuals supporting the concept of a single-payer system, or likely to support
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it over time and with pressure from advocates:
● State government: Jerry Brown (CA Governor), Anthony Rendon (Assembly Speaker), John
Chiang (CA State Treasurer, 2018 CA Gubernatorial Candidate), Antonio Villaraigosa
(Mayor of Los Angeles, 2018 CA Gubernatorial Candidate)
● Federal government: Kamala Harris (US Senator), Bernie Sanders (US Senator)
● Consumer advocacy: Health Access California, Consumerwatchdog.org
● Health foundations: Blue Shield of CA, CA Health Care Foundation, The CA Endowment,
The CA Wellness Foundation
● Social services: Western Center on Law and Poverty
● Research: Jim Kahn (UCSF), Stephen Shortell (UC Berkeley)
● News organizations (e.g., editorial boards): Los Angeles Times, San Francisco Chronicle, smaller
newspapers covering California cities and counties
c) We also seek to draw support from unconventional allies, or people who have traditionally not been
involved in campaigns for health care reform or single-payer. These unconventional allies may be of
substantial help for the coalition, because of their high social, cultural, and financial capital.
Unconventional allies include:
● Technology: Mark Zuckerberg (CEO of Facebook), Sheryl Sandberg (COO of Facebook),
tech start-ups
● Other policy entrepreneurs: Warren Buffett (CEO of Berkshire Hathaway), Charlie Munger
(former VP of Berkshire Hathaway)
● Celebrities: Jimmy Kimmel (Television show host), John Legend (Singer), America Ferrera
(Actress)
d) Due to supposed cost increases and significant government oversight, we expect significant
opposition to the reintroduction of SB 562 or to a new bill. Opponents include:
● State government: Assembly and Senate Republicans
● Health plans: America’s Health Insurance Plans (AHIP; members include Anthem, Blue
Shield of CA, Kaiser Permanente), CA Association of Health Plans (CAHP), Local Health
Plans of CA (LHPC)
● Business: CA Chamber of Commerce
● Research: Pacific Research Institute
● News organizations: California newspapers covering more conservative areas (e.g., Orange
County, San Diego, rural areas), national media organizations (e.g., Fox News, Breitbart
News)
● Conservative policy entrepreneurs: Koch Brothers
● Federal government: Trump administration, GOP Senators and Representatives

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PowerAnalysis
The following diagram illustrates a power analysis of the key stakeholders among single-payer
supporters, as well as several members of the opposition. The horizontal axis indicates the level of
support a given organization or individual has for or against single-payer. The vertical axis reflects the
degree of influence an organization or individual has in shaping the trajectory of the issue. The power
analysis is a dynamic map, as it can be reorganized throughout the campaign as players shift positions
and build (or weaken) influence.

Fig. 6 - Power analysis.
To note, unconventional allies are grouped together as a single point in a neutral positive area,
as it is relatively unknown how much support and influence they wield during the pre-bill
introduction phase.

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6. Bill Construction
After the analysis has been conducted and circulated, the coalition should work with current authors
of SB 562 (i.e., Lara, Chiu, etc.), as well as Speaker Rendon to ensure full-fledged support of the bill.
The bill should be tailored as closely as possible to the policy and economic analysis’
recommendations, as much criticism pointed to the rushed nature of the bill and lack ofs reputable
analysis.

Fig. 7 - Trade-offs between introducing a new bill and revising SB 562.
B. Post-Bill Introduction
1. Bill and Report Introduction
The report should be released to the general public a month before introduction of the bill.
Once the report has been pushed by the coalition into the media, a large amount of pomp and
circumstance should be used for the introduction of the bill. A politician with high approval should be
used, like previous speaker Toni Atkins.
This bill introduction ceremony should take place at the state capitol with the full coalition
utilized and at the ready. With a large crowd, free media should be gained, alongside paid media from
the foundation dollars that will be used by all arms of the coalition.

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Fig. 8 - Introduction elements.
2. Communications: Media Campaign
The current SB 562 coalition has undertaken various communication efforts across traditional
and social media. Recognizing that there is an ongoing media campaign that has started building
visibility for the cause, we propose that advocates continue upholding the values associated with
single-payer (e.g., justice, equity, opportunity to achieve health and well-being) and with existing
communications efforts, but also aim to expand the frames, messaging, and narratives to appeal to
broader audiences and thereby augment public support.
As mentioned, various stakeholders have significant concerns about how single-payer would
be financed and carried out in California. The failure of SB 562 to pass in the Assembly has reiterated
the predominant narrative that single-payer is currently not a realistic and fiscally responsible
undertaking for California. Moreover, given the opposition’s past success with undermining
single-payer efforts in California and across the country, it is essential that this advocacy campaign
revamp counter-frames, -messages, and -narratives beyond the commonly used, “Health care is a
human right” frame and subsequent messaging. Frames and messaging may include but are not limited
to:   21
California is a policy leader: “Who are we as Californians? We are leaders.”
Californians value health for all: “Are we saying that we can’t achieve universal health care?”
The Trump administration and GOP are Public Enemy No.1 and threats to California:
“If the ACA is successfully repealed and replaced, then the consequences for
Californians would be disastrous.”
“We need to continue the resistance against the Trump administration.”
Health care is an economic issue and linked to growing economic inequality:
“No woman, man, or child should go bankrupt because of health care costs.”
“Single-payer is pro-business.”
The current health care system is broken and rigged.
“Single-payer is the innovative disruption that the health care system needs.”
Given increased and well-funded communications efforts, we hope to grow the coalition
beyond what was previously possible.
a) Traditional Media
Traditional forms of news media will continue to play a role in communicating to the public.
Newspapers
21
The frames and messaging used will have been tested from focus groups.
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Advocates should target a diversity of newspapers across California that cover varying
geographic areas, population sizes, political ideologies, and languages. The coalition should aim to
produce op- eds and pitch stories to reporters that leverage the diversity of its membership, but also
maintain cohesiveness for the organization. When possible, advocates should contact reporters and
write op-eds in their respective community’s newspaper, particularly for publications with smaller,
more localized audiences. For widely read newspapers like the Los Angeles Times, the coalition should
plan to roll out several pieces featuring different voices from its membership.
● Publications with wide circulation: e.g., Los Angeles Times, San Jose Mercury News, The
Sacramento Bee, San Francisco Chronicle, The Orange County Register, The San Diego
Union-Tribune, Contra Costa Times
● Publications with smaller circulation: e.g., The Press-Enterprise, San Gabriel Valley Tribune,
The Daily Breeze, The Modesto Bee, The Press Democrat, Long Beach Press-Telegram, Inland
Valley Daily Bulletin, The Tribune
● College and university student publications: e.g., The Daily Californian, Daily Bruin
● Publications in non-English languages: e.g., La Opinión, The Korea Times
Incorporating the frames and messages based on polling and focus groups, stories from
newspaper reporters or coalition members should address, but are not limited to:
i. Findings and conclusions from policy and economic analyses on implementing single-payer
in California: A nonpartisan entity (e.g., The Commonwealth Fund) should conduct a rigorous study
on the costs and benefits of single-payer in California. The study will serve as a critical resource for
evidence-based policymaking, which Senators and Assemblymembers can have strong confidence in
citing. In general, a greater effort should also be made to translate and communicate health policy
research from academics and centers (e.g., UCLA Center for Health Policy Research, UC Berkeley
Labor Center) into accessible and compelling stories for broad audiences.
ii. Financing single-payer health care: One major critique repeatedly coming from the
opposition and other non-supporters concerns the gaps in SB 562 regarding the costs of implementing
single-payer. The cost to undertake single-payer and the subsequent short- and long-run savings should
be addressed head-on with strong evidence from research, and accompanied by illustrative case studies
from patients and healthcare providers detailing their experiences of navigating the healthcare system’s
high costs. Pieces will also include visually-appealing and easily digestible statistics projecting health
care costs and savings under single-payer for different demographic groups (e.g., a family of four, an
unmarried working adult, children, college students).
iii. Political considerations under a Trump administration and GOP-controlled Congress: As
the ACA continues to come under attack from politicians in Washington, defending the ACA has
been one of the Democratic Party’s top priorities. However, as many Democrats and progressives in
California have recognized, it is time to go beyond protecting the ACA and aim for single-payer
healthcare. Op-eds should seek to justify and legitimize the political feasibility of moving forward with
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single-payer in California, demonstrating that it is the more politically sound and sustainable route
than continuing a back-and-forth battle with Republicans’ attempts to replace and repeal the ACA,
and at the very worst, a definite future with no ACA.
Radio
As conservatives have successfully used talk radio to promote their views and engage audiences,
the coalition should utilize radio shows (e.g., talk radio, podcasts) to communicate the benefits of
single- payer healthcare and to urge listeners to call their representatives to support the revised bill. The
coalition may also select representatives to participate in debates on shows of different political
leanings, so as to expose more conservative audiences to the case for single-payer. In addition, radio ads
for single-payer should go on during peak hours of listening (e.g., morning and evening commutes,
midday). Broadcasting the campaign on the air will help reach a wide swath of audiences across
demographic age groups (e.g., millennials, Gen X, Baby Boomers) and easily cover wide geographic
areas.
Advertisements
To increase reach, the coalition will continue sponsoring advertisements on local news
channels, billboards, and public transit. With approval, the campaign should feature its diverse
coalition members and their stories on the ads, using both everyday people whom different types of
audiences can identify with and people with name recognition.
b) Social Media
An organized and strategic campaign will also continue to be conducted across multiple social
media platforms, including Facebook, Twitter, Instagram, and Youtube. Social media should be used
to document the campaign’s ongoing activities, amplify its messages, and garner support from diverse
audiences. Best practices for how to effectively and efficiently use social media as a non-profit entity
can be found in online guidebooks and articles.
3. Events
As part of the campaign’s on-the-ground engagement, the coalition will hold several different
types of events post-bill introduction. At the time of writing this plan, the SB 562 coalition has
organized door-to-door canvassing, marching in parades, rallies across the state and in the capitol, and
“packing the halls” of the Select Committee’s hearings. These types of grassroots activities should
continue, and to add to the series of events, the coalition should host forums and townhalls on
single-payer health care across the state and a gubernatorial debate on health care reform. The 2018
Governor’s race in California will be widely watched, and this timing can be used to the advocacy
campaign’s advantage. Whether it is Gavin Newsom, John Chiang, or another candidate who becomes
the next governor, a gubernatorial debate presents the opportunity to apply further pressure on
candidates to support single-payer, or cast non-supporters as unviable for California. Once the new
governor takes office, advocates will have a strong case to keep the governor accountable on his or her
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promise for advancing single-payer.

4. Working Against the Opposition
To wage an effective media and on-the-ground campaign against the opposition, the
overarching communications strategy and response tactics must be agreed upon by all members of the
coalition. If reacting to the opposition, the coalition should do so with a unified message. Individual
members should not speak out as representing the coalition’s views, without first consulting the
coalition. It is important to have proactive measures in place to avoid fragmentation in the coalition.
As informed by polling and focus groups, the frames and messaging will counter the
opposition’s criticism. For example, when the opposition claims that now is not the time for single-
payer due to the impossible political and financial barriers, one possible counter is: “Who are we as
Californians? Are you saying we can’t achieve health care for all?” Rather than accepting the
opposition’s frame that single-payer is a lofty policy goal, the coalition subverts the frame with this
counter-frame, insinuating that the opposition does not fundamentally identify with Californians and
their values.
Considering the Trump administration and GOP’s persistent efforts to eliminate the ACA,
there will certainly be negative opinions expressed and even funding directed at quashing the
single-payer campaign in California. The campaign should anticipate attacks from Trump,
Republican lawmakers, the conservative news media, and conservative think tanks. As the federal
government is a particularly volatile arena that is difficult to predict, we recommend that most
advocacy work steer clear of the federal government as much as possible. However, if the coalition 22
decides to respond to Trump’s tweets, for example, the response should be carefully crafted and used
to augment the issue (as the news media will likely pick it up).
Perhaps most concerning from the opposition is the money flowing from health plans, health
care organizations against a single-payer system, and wealthy conservative policy entrepreneurs (e.g.,
Koch Brothers), which have influence over California lawmakers through campaign donations or
other financial incentives. Moreover, these well-funded opposition members can easily pay for and set
up a public relations campaign, and do so more quickly than the coalition. Advocates will need to keep
a careful eye on how the opposition is funded and note which Senators and Assemblymembers have
received or will likely receive donations, such that they may deliberately target and pressure these
lawmakers. The media campaign will also aim to directly assert counter-frames and -narratives to
neutralize the opposition’s public relations efforts.
6. Internal and External Strategy Lanes
22
If the state does desire some funding assistance from the federal government, it will likely need to apply for a 1332
Waiver. While it is unlikely this waiver would be approved, the coalition should leverage Republican support of state’s
rights to allow the state as much autonomy as possible in the implementation and use of federal dollars towards
single-payer.
16

Throughout the post-bill process, it should be emphasized within the coalition there are two
“swimlanes” of advocacy: internal and external. Any problems with messaging or the bill should not be
made public; instead, coalition members should communicate their concerns internally and put the
item up for discussion within the group. A united front, alongside internal collaboration with
California Legislature, will make the strongest coalition possible.
IV. Campaign Timeline
Pre-Bill Introduction
Fall 2017 - Spring 2018: Conduct research, recommend best single-payer plan.
Winter 2017 - Fall 2018: Build coalitions, secure funding from foundations, and acquire
endorsements from Senators and Assemblymembers.
Summer 2018: CA Legislature reconvenes after Spring Recess, introduce single-payer bill.
Increase coalition building efforts through grassroots and media campaign.
Post-Bill Introduction
Fall 2018: Push bill through process and have signed by Governor by end of session.
Winter 2018 - Onward: Program implementation.
V. Personal Issues
As with any graduate-level report, this advocacy plan was very difficult to compose. From an
egotistical standpoint, we feel that we must have some amount of hubris to even consider making an
impact on an issue as large as single-payer.
Looking at struggles, the items we most had problems with were forming a plan that took all
advice into account. Among the advocates we spoke to, they often had strikingly contrasting
viewpoints. This made it difficult for us, as we felt compelled to choose between viewpoints. Even
further, we sometimes disagreed with some advice – this had us wondering if we were truly correct, or
if we were turning our nose in the face of advice from others who had been working on this issue for a
very long time. For example, we are more open to other ideas of universal care, while those we spoke to
were entrenched in single-payer. If any other method of universal coverage was suggested, they
indicated that they thought it would still fall short (like the ACA) and opposed the idea.
We have collaborated on previous projects, so working as a team was quite successful. While
our mindsets are quite contrasting, they actually make a successful combination – one of us is
polychromatic and flowing to give the paper feeling, while the other is more methodical and critical to
make sure the plan is pragmatic. For both of us, it is extremely exciting to work on an issue that we care
about deeply. We have no ethical concerns and are hopeful that this project may inform our
educational and professional career. Most important, we present this advocacy plan with a hope that it
can support a worthwhile cause, and an openness to continually learning how to be better advocates
for public health.
17


VI. Appendix

Fig. 9 - Challenges to the advocacy campaign.

Fig. 10 - Strengths of the advocacy campaign.

18

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