1. Communicating about Medicaid Expansion in Remaining States. Families USA | January 2015

2. Attitudes are different. Messaging may be different too. 2

3. Where they start. Are not paying attention to this issue. Have not heard that their state turned down money to expand Medicaid. Do not know their governor’s position (Utah an exception). Unhappy about the ACA. Wary of federal government. Feel politicians are not trustworthy. Highly skeptical of information. Uninformed and conflicted about Medicaid. Assume Medicaid’s income eligibility levels are higher. Have not heard of the “coverage gap.” 3

4. Framing the decision. Expand Medicaid Cover More Uninsured Create “Healthy [STATE NAME]” Close the Coverage Gap 4

5. Obstacles. Federal government involvement. The 10% state share. Explaining the 100% federal government funding. Believe their taxes will go up. Do not know Medicaid levels are so low. Unaware people have fallen into the coverage gap. Do not want another government “hand out” program. There are few trusted messengers. 5

6. Opportunities. Want to help working families. Are surprised Medicaid levels are so low. Can be educated about the coverage gap. Hearing the money is already earmarked makes them feel they would be foolish to turn it down – use it or lose it. A hospital fee to cover the 10% works well. Hearing the expansion could be “cost neutral” is effective. University researchers/economists are trustworthy. If the governor is behind a plan, that can help. Talking about economic benefits to the state could help. 6

7. Waiver ideas. They support these ideas – they want personal responsibility and accountability. But after “checking the box” they do not want these rules to be burdensome or keep someone from care. We can engage in these discussions in an effective way… Premiums: modest, sliding scale, grace periods for non-payment Copays: $5-$10, no copay for preventive care Healthy behaviors: discounts and incentives – not financial penalties, worried about going too far, hard to monitor Work requirements: our biggest challenge, hard to monitor, aren’t these working people? 7

8. What worked. “Working families.” Give sample income ranges of those who are eligible. Describe industries they work in (construction, child care, janitorial services, landscaping). Define the coverage gap. Researchers/economists estimate this plan will be “cost neutral.” 10% state share will be paid by a new fee on hospitals – not new taxes on you. The state can opt out at any time. The money has been set aside by the ACA. If we do not accept the money, the federal government will keep our taxpayer dollars (not “the money will go to other states”). If we do nothing we will still have to pay for the uninsured who use hospital ERs. 8

9. Sample messages. “Hardworking families in [STATE NAME] need the security of quality health care coverage to get care when they need it, without facing huge medical bills or going into bankruptcy.” “Already XXX,XXX state residents have fallen into the “coverage gap.” This means their incomes are too low to qualify for tax credits through HealthCare.gov and too high to qualify for Medicaid. They are stuck in the middle with no affordable insurance options because the State Legislature will not accept federal tax dollars that were set aside to help them get coverage.” “If you or someone in your family lost their job and insurance, affordable coverage would be there while you got back on your feet.” “Governor [NAME] and the State Legislature can back out at any time after they accept the federal tax dollars and expand health coverage. If it is not working or costing the state too much money, they can change their mind. There is no risk, so why not accept the money?” 9

10. Sample messages. “If the State Legislature turns down the money, the federal government will keep our tax dollars. In [STATE NAME], we are losing $X,XXX,XXX a day, which has added up to $XXX million dollars so far. We should spend our own tax dollars to help hardworking families in [STATE NAME] who need health insurance.” “We can use the federal tax dollars to reform [STATE NAME] Medicaid program, making it more efficient while helping more uninsured state residents get affordable health insurance.” “It is a wiser use of our taxpayer dollars to pay for preventive care through an expanded Medicaid program rather than continue to have uninsured state residents use the ER when they are already sick and cost more to take care of.” “A report sponsored by the state estimated that the expansion could bring as much as $XXX million in economic benefits to [STATE NAME] during the first three years of implementation. Because more people would now be using health care, the same report predicted the expansion would create X,XXX new jobs, most of them in the health care area.” 10

11. Wrap Up. In these states, pragmatism wins out – “use it or lose it.” What moves them there… Redefining this population as “working families,” giving their income range, and naming the types of jobs they have. Telling them how low state Medicaid levels are (especially in TX and FL). Describing the coverage gap. Explaining the money has already been earmarked for this. Telling them the state can opt out at any time. Saying the 10% fee will be paid by hospitals. Describing the plan as “cost-neutral.” Including waiver ideas – modest premiums and copays and encouraging healthy behaviors. 11