Project CHARGE: Building an Urban Health Policy Advocacy Community

Abstract

Background: The Coalition for Health Access to Reach Greater Equity (Project CHARGE) is a health policy advocacy coalition devoted to improving healthcare access for Asian Americans in New York City.

Objectives: This paper discusses Project CHARGE’s strategies for building a successful coalition.

Methods: Findings are based on evaluation data from field observations and surveys of Coalition representatives.

Lessons Learned: (1) Health policy coalitions can gain strength by recruiting from a wider range of organizations; maintaining a diverse coalition requires developing strong relationships among members. (2) Locally focused health policy coalitions should consider modifying course if needed to respond to policy developments at other governmental levels. (3) Health service providers can help to sustain policy advocacy activities if sufficient training is provided to develop them into policy advocates. (4) Early successes need to be planned to galvanize Coalition members.

Conclusions: Aiming to build a policy advocacy “community” may help to ensure that advocacy continues even when funding is scarce.

In New York City, one in eight Asian Americans goes uninsured within a year, and the overwhelming majority of uninsured Asian Americans in New York City are foreign born (83% or 65,000 people).1 Healthcare access problems are exacerbated in Asian communities by undocumented immigration status, language barriers, cultural stigmas regarding public benefits, low utilization of primary and preventive care, and high rates of employment in small businesses or cash-based industries that are less likely to offer health benefits. Remedying these healthcare access problems often requires policy or systems change; unfortunately, Asian Americans are routinely left out of policymaking processes that might address their concerns. The creation of a unified advocacy effort to address Asian American healthcare access concerns in New York City has been long overdue.

In January 2008, New York City-based Project CHARGE became one of 12 grantees in ten states funded by Health Through Action, a $16.5-million national initiative organized by the Asian and Pacific Islander American Health Forum with funding from the W.K. Kellogg Foundation to support local, community-based projects working to reduce health disparities among APIs. Project CHARGE is a collaborative of 14 organizations (Table 1) that works toward increasing access to healthcare for Asian Americans in New York City through policy advocacy. Although the Project CHARGE partner organizations represent a wide range of Asian ethnic subgroups and populations served, number of years established, and issue areas addressed, they came to together out of a shared concern for the lack of visibility and political voice for Asian Americans in health policy. Project CHARGE member organizations chose the Coalition for Asian American Children and Families from among its ranks to be the lead grantee agency and to staff the Coalition.

Methods

Our findings are based on an ongoing program evaluation of Project CHARGE required by the funder and conducted by an external evaluator, who was hired by the Coalition and is a co-author of this paper. Institutional review board approval was not sought because the co-authors’ institutions do not require review or approval of program evaluations required by funders. The program evaluation consists of an annual evaluation survey that is completed by each member organization representative and field observation conducted by the program evaluator at Coalition monthly meetings. This paper is based on the survey and field observation data.

The annual survey was administered three times (July/August 2008, 2009, and 2010) and was designed to measure changes in policy advocacy capacity of Coalition members, satisfaction with the Coalition’s activities and leadership, and the strength of social networks among Coalition members. In the social network portion of the survey, each of the 14 organizational representatives were asked several questions about each of the other organizations, such as whether they knew the representative’s name and face and the number of times they had work-related contact with the organization. Survey data were analyzed using Excel (Microsoft, Redmond, WA), SPSS (SPSS, Inc., Chicago, IL), and SAS (SAS Institute, Cary, NC).

Table 1.

Project CHARGE Member Organizations and Basic Characteristics

Field observation data were reviewed by the program evaluator, and dominant themes were identified. These themes were then refined and developed through analytic discussions with the Coalition’s director (who co-authored this paper). Further development occurred through collaboration between the program evaluator and Coalition director on several drafts of this paper. Moreover, the paper was distributed to all Project CHARGE members, and their comments were invited and incorporated into the paper. Two Project CHARGE members (aside from the co-authors) volunteered to conduct a more thorough readthrough of the paper and provided extensive comments, which were incorporated into the final version.

Results

Below, we review the Coalition’s successes and challenges to date, which fall into four thematic areas: (1) Building a diverse community, (2) managing change, (3) developing service providers into advocates, and (4) maintaining momentum. For each area, we describe the problem or the challenge, the Coalition’s approach to addressing the problem or challenge, and the results to date.

Building a diverse Community

Perhaps the most unique challenge for an Asian-focused policy advocacy coalition is the lack of Asian-American voting blocs that might give teeth to its advocacy efforts. Aside from constituting a relatively small group, Asian Americans have lower voter registration and turnout and are more geographically dispersed than other racial/ethnic minority groups.2 To build a broad base, the Coalition had to bring together organizations serving a variety of Asian ethnic groups and working in a wide range of areas, casting its net beyond strictly health policy organizations, of which there are few that focus specifically on Asian-American concerns. Populations served by Coalition organizations include Bangladeshis, Chinese, Filipinos, Indians, Japanese, and Koreans. Ages of Coalition representatives ranged from 24 to 74 years (median, 35). The organizations represented ranged in size from 1 to 400 staff and worked in a variety of areas, including public health, social work, mental health, HIV/AIDS prevention and care, health research, medical care, housing, domestic violence, immigrant services, youth development, senior services, community development, and policy advocacy.

Before receiving funding, the partners had been meeting to develop the grant proposal that led to being funded. After notification of the grant award, Coalition organizers prioritized the building of strong relationships among its diverse members by devoting the funded Coalition’s first formal meeting—a day-long retreat in January 2008—to team-building exercises and developing a shared guiding vision. For example, an external facilitator who was brought in for the retreat had participants explore their group work styles and identify ways to tap the strengths and minimize friction resulting from different styles. Portions of the retreat were devoted to clarifying the Coalition’s decision-making procedures and advocacy goals. Building this pan-ethnic Asian American policy advocacy community has also been facilitated by a group listserv and regular monthly meetings.

Observations of coalition meetings held monthly since 2008 suggest strong cohesion and engagement among Coalition members. Social network analysis of measures collected each summer as part of the ongoing program evaluation research suggest that Coalition members increased interaction with each other outside of Coalition meetings between the first and second years. For instance, some partners have collaborated on writing grant proposals, co-sponsored symposiums (i.e., an event commemorating National Asian and Pacific Islander HIV/AIDS Awareness Day and a conference on Asian-American health), and served as ongoing resources for each other by providing information and accepting referrals of clients from each other. A social network measure from the evaluation survey, which shows that each Coalition representative knew on average about 11 other Coalition representatives by name and face and that this measure remained fairly constant over the 3 years, suggests both the success of relationship-building efforts and the need for improvement. Although Coalition members seem to be relatively familiar with each other, it is concerning that in a relatively small coalition participants on average did not know 2 out of 13 other Coalition members by name and face over the 3 years of evaluation. This is partly explained by turnover among Coalition representatives: 3 out of 14 representatives changed between the first and second years, and 5 representatives changed between the second and third years.

Managing Change

The Coalition started at a time that was both difficult and promising. The impending change in the presidential administration in 2009 loomed large, and early in 2008, it was not clear which policy battles were most important, given that much of the policy terrain might change radically within a year. Given the level of uncertainty, the Coalition chose a tactic of flexibility to be responsive to new developments, even if that meant shifting from a state/local- to a federal-level focus.

In its early meetings, the Coalition agreed to prioritize advocacy efforts at the state and local levels to increase affordability and linguistic accessibility of health services for Asian Americans. Later, in light of the prospect of major healthcare reform at the national level under the Obama administration, the Coalition decided to expand its work to focus on national healthcare reform proposals to ensure that Asian-American needs would be addressed. In accordance with this expansion, five Coalition agencies participated in legislative visits in Washington, DC, in June 2009 to meet with members of congress representing New York State to educate them on Asian-American healthcare needs and offer recommendations for healthcare reform. Additional advocacy efforts at the national level included letter-writing, phone, and e-mail campaigns. Many of the Coalition’s policy priorities became provisions in the final Affordable Care Act (ACA) passed in March 2010, including disaggregated API data, cultural competency, language access, and increased funding for community health centers.

Since the passage of the ACA, the Coalition’s federal-level activities have diminished, but its state-level activities have increased as the Coalition keeps its eye on ACA’s roll-out at the state level. An important indicator of Project CHARGE’s success at the state level was its appointment to the New York State Governor’s Health Care Reform Advisory Committee. Project CHARGE was selected over a number of much more well-established health policy groups to be one of the 37 organizations on the committee. Its membership provides a strategic position for ensuring that the ACA’s implementation at the state level will be responsive to Asian-American needs. Project CHARGE also produced a report, “Healing the Health Care System,” which analyzes the implications of the ACA for Asian Americans in New York and makes recommendations targeted at the New York State legislature. Despite this difficult economic time, New York State elected officials have not retracted on promises to cover all children regardless of immigration status in households of up to 400% Federal Poverty Level and to not impose a 5-year ban on legal immigrants’ access to public benefits.

Developing Service Providers into Advocates

Except for the Coalition for Asian American Children and Families and an academic/research organization, members of the Coalition are primarily nonprofit service organizations. Twelve of the fourteen organizations provide direct services to clients. Project CHARGE’s experience suggests that health service providers can help to sustain policy advocacy activities if sufficient training is provided to develop them into policy advocates. Given the lack of political power noted and the scarcity of organizations devoted to health policy advocacy for Asian Americans, it was essential for Project CHARGE to have the involvement of Asian-focused service-providing organizations, who have relevant expertise and passion for improving the healthcare system. The difficulty is that most of these organizations are unaccustomed to engaging in policy advocacy work; research also demonstrates that nonprofit organizations lack awareness about the extent of political activity they are permitted to engage in and spend fewer funds on political activity than they are legally allowed.3 The task then was to develop these service providers into advocates.

To accomplish this goal, Coalition organizers structured a number of the monthly meetings around building policy awareness and advocacy skills of members (Table 2). Early meetings included presentations by representatives of government agencies to discuss healthcare affordability issues and programs currently available to improve affordability. Later meetings featured representatives of other coalitions and advocacy organizations to update or train members. Training topics included the legislative and budget process in New York City, federal healthcare reform proposals, and developing talking points for discussions with media and policy makers.

Through training, Coalition members learned to identify and foster relationships with key decision makers and became more adept at speaking with legislators and the media about Project CHARGE’s advocacy agenda. Many Coalition members had their first taste of policy advocacy work during the legislative visits in Washington, DC, which allowed them to utilize their newly acquired skills. Additionally, Coalition members appeared on NY1, a local news channel, which aired a segment featuring Project CHARGE’s work.

These smaller forays into policy advocacy culminated in Project CHARGE’s State Advocacy Day in May 2010. Project CHARGE’s lead organization, which has significant policy advocacy expertise, led a day-long training to prepare Project CHARGE members and coordinated materials and logistics for the day itself. The day was a huge success as measured by Coalition member participation and by state legislators’ positive response. Many legislators’ gave Project CHARGE members considerable time and attention, close to an hour in some cases, and several legislators contacted Project CHARGE members immediately after the visits to thank them and discuss follow-up. Coalition members came away from state advocacy day feeling more confident in their policy advocacy abilities.

Maintaining Momentum

A significant challenge in developing this Coalition has been maintaining momentum and interest of the members. In the Coalition’s early period, which was devoted to developing ties among members rather than on externally directed policy advocacy activities that might help to galvanize the coalition, Coalition organizers coordinated several strategic events that helped to maintain members’ motivation. Project CHARGE’s experience suggests that planning for some early “successes” can help to galvanize coalition members and carry the coalition through more routine or difficult periods. For example, a press conference to introduce the Coalition to elected officials and the general public was planned to be held at New York City’s City Hall in February 2008 (Figure 1). It was attended by key state and local elected officials, including New York State Assembly Member Richard Gottfried, chair of the Assembly’s Health Committee. The press conference resulted in at least six articles in Asian ethnic newspapers and was attended by 13 of the 14 Coalition member organizations. The press conference helped with brokering a follow-up meeting with Assembly Member Gottfried in April 2008 to discuss how he might help in furthering the Coalition’s objectives. This meeting was attended by 11 Coalition member organizations.

Table 2.

Project CHARGE Policy Advocacy Training Topics

Despite challenges of maintaining momentum, records show that attendance at monthly meetings has been stable, with an average attendance of between 10 and 11 organizations (out of 14 Coalition organizations) for all 3 years of the Coalition. In addition, 6 of 14 organizational representatives remained constant throughout the 3 years. High satisfaction with Project CHARGE’s leadership and with the Coalition’s direction may have helped to sustain overall stability of attendance. For example, on a scale of 1 to 5 (1 = “very dissatisfied” and 5 = “very satisfied”), Coalition representatives rated “the way Project CHARGE is run overall” at 4.6 on average and the “clarity of Project CHARGE’s direction” at 4.3, indicating that Coalition representatives were between satisfied and very satisfied in these areas. Any flagging of motivation in the later period of the Coalition may have been remedied in part by Project CHARGE’s State Advocacy Day, which was attended by 13 out of 14 member organizations and reaffirmed the importance of the Coalition’s mission and purpose. State Advocacy Day was also an opportunity for Coalition members to practice their advocacy skills in the real world. The chance to learn new skills and increase knowledge that might help them in their work seemed to be an important motivator of Coalition representatives’ participation.

Maintaining motivation of the individuals representing their organizations in the Coalition is complicated by the constraints put on some representatives by the senior management of their organizations. Aside from the lead agency, which is allotted extra funds to manage the Coalition, Coalition member organizations receive only $4,000 annually and are expected to attend monthly meetings and be involved in between-meeting activity. Not surprisingly, Coalition representatives indicated the least satisfaction with funding level, rating this item at 3.6 on average (between neutral and satisfied) on the annual survey. Because of the low funding level, some senior managers have found it hard to justify allotting significant staff time for Coalition participation. For the Coalition to expand into more vigorous policy advocacy activity, members will have to devote even more time to the Coalition’s work. To some degree, the Coalition’s success with State Advocacy Day and its appointment to the Governor’s Health Care Reform Advisory Committee has helped to establish its value in the eyes of senior managers of member organizations, who might be more inclined after these successes to support their staff’s involvement in Project CHARGE. Nevertheless, increasing Project CHARGE’s scope of work will be a continuing challenge without sufficient funding to staff the coordination of the Coalition and to support release time of staff members of participating organizations.

Figure 1.

Project CHARGE members at a press conference on February 19, 2008, to introduce the Coalition and its policy agenda to decision makers and the public.

Starting fourth from the left, standing, are New York City Council Member Alan Gerson; New York State Assembly Members Richard Gottfried and Ellen Young; Suki Ports, executive director of the Family Health Project (in front); Wayne Ho, executive director of the Coalition for Asian American Children and Families (in back); and Marguerite Ro, deputy director of the Asian & Pacific Islander American Health Forum.

Conclusion

Our program evaluation of Project CHARGE suggests that health policy advocacy coalitions working on behalf of smaller populations can gain strength by casting a wider net to recruit member organizations, drawing on diverse organizational types and subgroups within the target population. Service-providing organizations are more numerous than health policy advocacy organizations and can provide needed expertise and human resources to sustain health policy advocacy activities if sufficient training is provided to develop service providers into policy advocates. Building a successful coalition of diverse members requires paying special attention to developing strong relationships among members. Galvanizing members in a health policy advocacy coalition and maintaining their interest may be aided by planning activities through which members can experience early successes. A press conference to introduce the Coalition to the public served this purpose for Project CHARGE in its early period, and more ambitious efforts such as State Advocacy Day, in addition to furthering the Coalition’s advocacy goals, served a similar galvanizing purpose in the Coalition’s later period. The Coalition also maintained its vitality by being responsive to change and modifying its course and scope to address new policy developments at levels of government it had not intended to prioritize.

To sustain its expanded focus beyond the local level, Project CHARGE will need more funding to support adequate staffing of the Coalition and increased involvement of Coalition members in further advocacy training and in policy advocacy activities requiring out-of-town travel. As it nears the end of its current funding period, the Coalition has begun exploring new funding options and considering the feasibility of maintaining the Coalition without funding. Maintaining the commitment of the senior management of member organizations will be critical to the viability of the Coalition, especially if financial resources to support involvement remain limited. Nevertheless, thinking in terms of developing a policy advocacy “community” through strengthening ties and building capacity may help to ensure that policy advocacy efforts continue even if formal structures to support the work fall away.