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Consumer Voices for Coverage: Fostering Advocacy Infrastructures

For at least the past decade, health foundations have supported state initiatives to expand coverage. These initiatives include grants to national and state organizations or task forces to study the problem, estimate the effects of alternative solutions, and provide or secure technical assistance. Some foundations have also funded direct efforts to increase enrollment in Medicaid and State Children’s Health Insurance coverage.

Beginning in 2008, the Robert Wood Johnson Foundation (RWJF) launched the Consumer Voices for Coverage grant program (CVC) to support coalitions of consumer groups to advocate for expanded coverage and other health reforms in their states. The foundation made three-year grants in 12 states—California, Colorado, Illinois, Maine, Maryland, Minnesota, New Jersey, New York, Ohio, Oregon, Pennsylvania, and Washington—and Mathematica evaluated the program.

Foundations have traditionally been somewhat hesitant to fund advocacy, because of concerns they might appear too partisan or grantees might use the funds for lobbying activities prohibited by federal tax rules governing private philanthropy. In addition, the effects of advocacy—and hence, its value—are hard to measure. RWJF wanted to learn how the advocacy networks were structured and how they operated; whether their ability to advocate increased during the initiative; and whether, and to what degree, consumers shaped state policy on health insurance coverage. The foundation was particularly interested in developing lessons applicable to funding advocacy efforts in the future.

Mathematica surveyed the CVC coalitions’ leadership teams and used social network analysis to examine the coalitions’ structure, member characteristics, and relationships. We developed an instrument to measure six core capacities needed for successful health advocacy. We interviewed health policymakers in each state to examine consumers’ participation and influence on public policy debates over health coverage and health care in their states. We collected baseline data when the grant began as well as follow-up data during the third year of the grant, and used creative approaches to integrate data across states and over time as a way to examine impacts.

Evidence shows that consumer advocacy coalitions in most states coalesced quickly and strengthened their relationships over time, though coalitions in some states faced early or continuing barriers to forming strong partnerships. Advocacy capacity increased over time, though the capacity to raise funds remained low. Media and communications skills grew the most. The formation of broad consumer coalitions and their enhanced advocacy capacity helped increase consumers’ participation in health reform debates in their states, along with their access to and influence on state policymakers.

The evaluation, completed in 2011, showed that funders can strengthen advocates' skills and influence. It also demonstrates evaluation approaches that can be used to evaluate advocacy.

Publications

Journal articles:
“Foundation’s Consumer Advocacy Health Reform Initiative Strengthened Groups’ Effectiveness,” Health Affairs (September 2011)

Evaluation reports:
"Consumer Voices for Coverage: Advocacy Evaluation Toolkit" (October 2011)
"State Policy-Makers' Views on the Role of Consumer Advocates in Health Policy Discussions" (January 2011)
"Building State-Level Advocacy Networks: CVC After Two Years" (August 2010)
"Building Advocacy Capacity: Where Grantees Started" (September 2009)
"Leadership Team Member Organizations and Coalition Structures: Aggregate Findings from the Leadership Team Network Survey" (June 2009)
"State Policy-Maker Views on the Role of Consumer Advocacy Groups in Health Coverage Policy Development: Summary of Findings" (January 2009)
"Summary of Focus Group Sessions at the 2008 Annual Grantee Meeting" (October 2008) 
"Advocacy Capacity Assessment Instrument" (July 2008)