Introduction

State advocates have a critical role to play in the two fights looming over Medicaid - protecting existing Medicaid coverage against devastating budget cuts, and ensuring the implementation of the Affordable Care Act's (ACA) Medicaid expansion.

The recession has worn on state budgets for nearly five years, and states continue to face budget shortfalls in fiscal year 2013, placing extraordinary pressure on state policymakers to cut public spending and close budget gaps. As a result, many states are considering harmful Medicaid cuts: eliminating coverage, restricting critical benefits, and imposing premiums on those who can't afford them.

The ACA expands Medicaid coverage to 16 million new enrollees starting in 2014, but the Supreme Court's decision gave states the option of rejecting the expansion, putting the health of millions of vulnerable Americans in the hands of state government. 

Whether they're trying to prevent Medicaid cuts or ensure that states expand Medicaid, state advocates will need to:

• convince policymakers that Medicaid helps people and is popular; and
• present policymakers with savings and revenue options to support Medicaid

Advocates can use this Medicaid campaign planning guide to help develop their Medicaid campaigns in addition to this toolkit, which provides best practices and lessons from a number of states. Advocates can tailor the tactics, tools and resources in this guide to reflect specific expansion campaigns, strategies, or states' political environments when building the case for protecting and expanding Medicaid. 

Make the case Medicaid helps people and is popular

Tactic: Create a table of potential partners, allies, and stakeholders who can help build the case for Medicaid

Resources:

• Guide: State partners to engage on Medicaid defense and expansion work

Examples:

• Utahns for Medicaid Expansion Coalition
• Northeast Ohio Medicaid Expansion Coalition

Tactic: Collect stories to highlight Medicaid's current impact and the impact expanding Medicaid could have on individuals and families.

Resources:

• Storybanking Tool Kit

Examples:

• New Mexico Facebook page used to find consumers who rely on Medicaid
• Maryland story collection form
• Michigan story collection form

Tactic: Create and circulate a petition or sign-on letter in support of Medicaid

Resources:

• Care2 petition website
• Change.org petition website
• SignOn.org petition website

Examples:

• Michigan petition urging Governor Snyder to support the Medicaid expansion
• North Carolina petition urging Governor McCrory to support the Medicaid expansion
• Pennsylvania sign-on letter supporting the Medicaid expansion

Tactic: Engage providers in your campaign to promote Medicaid

Resources:

• Community Catalyst blog and article in Health Progress that highlights strategies for engaging hospitals in making the case for Medicaid
• Messages for engaging providers in your campaign to promote Medicaid - including community healthcentersand hospitals
• Template one pager to make the case that providers should be engaged in your campaign to promote Medicaid

Examples:

• Advocates in Utah worked with the Utah Medical Association to draft a resolution in support of the Medicaid expansion
• Brief highlighting Medicaid as a lifeline for Tennessee hospitals

Tactic: Help providers speak publicly about the importance of Medicaid and the need to protect and enhance Medicaid payments to providers. 

Resources:

• Template op-ed for providers to make the case for Medicaid

Examples:

• Utah Medical Association's endorsement of the Medicaid expansion. 
• Iowa Hospital Association policy brief supporting the Medicaid expansion
• Ohio Hospital Association media statement supporting the Medicaid expansion
• Brief from the South Carolina Hospital association that highlights the economic impact of the Medicaid expansion
• Indiana op-ed that highlights how the Medicaid expansion will benefit Indiana hospitals

Tactic: Help businesspeople or business organizations speak publicly about supporting Medicaid

Examples:

• The president of the Business and Industry Association of New Hampshire's testimony in support of Medicaid
• The South Carolina Small Business Chamber of Commerce weighs in with decision makers about the importance of Medicaid
• Op-ed from the Virginia Chamber of Commerce supporting the Medicaid expansion

Resources:

• State-specific estimates of increased employer penalties if state rejects Medicaid expansion

Tactic: Engage veterans groups to highlight the importance of Medicaid

Resources:

• Urban Institute report that breaks down, by state, the number and percentage of uninsured veterans and their families who will gain coverage from Medicaid expansion

Examples:

• Factsheet highlighting why the Medicaid expansion is good for Tennessee veterans

Tactic: Highlight how Medicaid advances health equity

 Resources:

• Urban Institute report that breaks down, by state and race/ethnicity, the number and percentage of uninsured adults who could gain health insurance coverage through the Medicaid expansion
• Center for American Progress brief highlighting how Medicaid will help LGBT people and their families get coverage

• National Health Law Program brief on the 10 reasons the Medicaid Expansion Helps to Address Health Disparities

Examples:

• New Mexico op-ed that highlights how the Medicaid expansion will benefit the Native American population
• Washington's MLK Lobby and Action Day, which included trainings, meetings with legislators and an action promoting racial equity
• Factsheet highlighting how the Medicaid expansion can benefit African Americans in Tennessee
• North Carolina brief that highlights how Medicaid can reduce health disparities
• Brief highlighting why the Medicaid expansion matters to Georgia's LGBT community

Tactic: Communicate effectively through traditional media about the importance of the Medicaid program.

Resources:

• Medicaid messaging document
• Template Pitch Note
• Op-ed template
• LTE template

Examples:

• Editorial supporting Medicaid expansion from the Albuquerque editorial board
• Op-ed that highlights why Medicaid should matter to all middle-class families
• Op-ed that highlights how Medicaid helps people in Washington state

Tactic: Communicate effectively through social media about the importance of the Medicaid program 

Resources:

• Medicaid and social media messaging guide

Examples:

• Merry Medicaid Tumblr
• Infographic examining the impact of the Medicaid Expansion on Colorado's economy
• Infographic showing that Medicaid Expansion is a smart investment for Pennsylvania
• Infographic highlighting what will happen to thousands of working Arkansans if Arkansas does not expand Medicaid
• Texas advocates' My Medicaid Matters Facebook page
• New Mexico advocates' YouTube video highlighting that Medicaid rocks
• The Insuring our Future partnership's YouTube video highlighting that Medicaid matters in Colorado

Other helpful toolkits

• Arkansas Advocates for Children and Families Medicaid toolkit -including great resources, videos, and infographics
• Tennessee Justice Center resource page with several factsheets on the Medicaid expansion and populations that will be helped

Savings and Revenue Options for Policymakers

Costs - whether they're perceived or real - are often the barrier to expanding Medicaid or protecting it against harmful cuts. Advocates have an opportunity to change the way policymakers think about Medicaid costs.  First, many of the perceived costs associated with the Medicaid expansion are outweighed by the savings the state would see in reduced uncompensated care and other expenses associated with the uninsured. Second, advocates can help policymakers move to a rational, progressive approach to sustaining the Medicaid program over the long term. 

Strategies to support sustainable Medicaid funding include: 

• Promoting the savings that expanding Medicaid may bring to your state
• Maximizing Medicaid revenue
• Reforming Medicaid payment and delivery systems to save your state money

Promote the savings that expanding Medicaid may bring to your state

Resources:

• Estimates of state costs associated with Medicaid expansion (that do not take into account all state savings)
• Guidance on Analyzing and Estimating the Cost of Expanding Medicaid

Examples:

• Arkansas finds expanding Medicaid could save the state $700 million, and Arkansas advocates promote Medicaid as a good deal for the state
• Pennsylvania advocates promote the savings associated with expanding Medicaid

Maximize Medicaid Revenue

Tactic: Increase provider and HMO taxes, and use this revenue to bring more federal Medicaid matching funds to the state to support Medicaid and health care.

Resources:

• Using provider fees to expand Medicaid

Examples:

• A report in Colorado examines various funding sources for sustaining the Medicaid expansion, including the state's existing provider fee

Tactic: Increase tobacco taxes, alcohol taxes, or taxes on sweetened beverages, and earmark the revenue for Medicaid.

Resources:

• Community Catalyst Campaign Guide:Raising Tobacco Taxes toSupport Health Access
• Resources on designing a sugar-sweetened beverage tax to support Medicaid or CHIP programs

Examples:

• Example: Advocates in Maryland succeeded at increasing the alcohol tax to help fund Medicaid

Tactic: Encourage policymakers to scour the state budget and identify current state services that could bring in additional federal matching payments.

Resources:

• Optimizing Federal Medicaid Revenues in Hard Times: A Primer

Reform Medicaid Payment and Delivery Systems

Promote payment and delivery system reforms that would save Medicaid dollars while improving patient care.

Resources:

• A webtool to help you identify how your state could better manage its Medicaid dollars
• A toolkit to help you promote payment reforms that would reduce potentially preventable complications and save millions of dollars

Examples:

• Advocates in Ohio promote more efficient payment and delivery systems as alternatives to more harmful Medicaid cuts