Where campaign ads mattered: health-related ballot initiatives

Television advertisements warning of dire consequences if voters passed single-payer health insurance flooded Colorado's airwaves this summer and fall.

While the creative minds behind the campaign took a lighthearted approach to lampooning the universal healthcare measure, which was championed by Vermont Sen. Bernie Sanders, they got deadly serious about the large payroll taxes that would supplant insurance premiums under the plan.

In one anti-single-payer ad, a cyclist rode full speed up a steep ramp into the side of a building. With a catchy jingle in the background, the voice-over said, “Sometimes you just know a bad idea when you see one, take Amendment 69 for example.”

“When you are on the 'no side' of a ballot measure, the ads can sometimes be obnoxious,” said David Keeney, a consultant for the “No on 69” campaign. “We wanted to educate people about the facts but also put a smile on their face.”

A major fear accentuated by the opposition was the $25 billion in taxes required to carry out the law, which would supplant the premiums paid by employers. Most of the opposition ads mentioned it in some way. “Tax increases of any sort are hardly ever passed in Colorado,” said Joe Hanel, senior communications expert at the Colorado Health Institute.

Opponents included not just the health insurance industry—Anthem donated a quarter of the $4 million raised to fight the measure—but the state hospital association. The “ColoradoCare: Vote Yes on Amendment 69” campaign raised just $890,000. The single-payer measure went down to defeat with just 21% of voters supporting it.

And so it went around the country for the most part. Controversial ballot issues that had a fairly strong base of public support when the campaigns began ultimately drew huge donations from special-interest groups opposed to their passage. The insurance industry mobilized to defeat Amendment 69 in Colorado, just as the drug industry mobilized to defeat a cap on some drug prices in California, spending $109 million compared with $19 million spent by proponents to pass the measure.

The best-financed campaigns didn't always determine the outcomes in the 25 health-related issues put before the voters in 13 states. Public health activists in the four cities considering small taxes on sugary sodas to curb consumption and fight obesity overcame a well-financed opposition funded by the grocery and beverage industries. Voters in Missouri decided to reject cigarette taxes even though the tobacco industry, in an unusual move, poured in millions of dollars to support the measures.

The pharmaceutical industry was ultimately successful in its $109 million effort to defeat California's drug cap measure. Some 54% of voters, or 5.5 million people, voted no on Proposition 61, a measure that would have allowed state agencies to pay for drugs at the same price negotiated by the U.S. Veterans Affairs Department. The VA's discount is estimated to range from 20% to 40%.

Proposition 61 began the election season with strong voter approval for drug price controls. But support waned as commercials opposing the proposal overwhelmed voters, said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation.

Kathy Fairbanks, spokeswoman for the “No on Prop 61” campaign, said the campaign benefited from the support of more than 200 organizations including many HIV-AIDS, LGBT, business and health groups, which told their members to reject the initiative, raising concerns about access to drugs. Physicians from the Colorado Medical Association, the California Association of Neurological Surgeons and other groups also joined the opposition.

Veterans were often featured in the opposition's advertising. In one ad, a member of Veterans of Foreign Wars said the measure will force veterans to pay more for prescription drugs. In another, a physician from the California Medical Association argued the law would harm patients and working-class families.

“The 'no side' was successfully able to make people think the measure would hurt veterans,” Hempstead said.

Charles Idelson, communications director of the California Nurses Association, said the pharmaceutical industry waged a campaign based on “deceit and threats.” The association contributed about $260,000 to the “Yes on Prop 61” campaign.

The “yes” campaign had about $19 million in contributions, overwhelmingly from the Los-Angeles based AIDS Healthcare Foundation, which donated $18.7 million.

Advertisements for the campaign directly called out the pharmaceutical industry. An ad featuring a veteran says, “Don't listen to the drug company's lies, Proposition 61 would lead to lower drug prices for everyone.”

Yet the message was ineffective in a media environment dominated by the other side. George Sillup, associate professor of pharmaceutical and healthcare marketing at St. Joseph's University, said the drug industry was able to successfully control the message of Prop 61 because it sets prices.

Hempstead at the RWJF said California voters probably heard this threat from the pharmaceutical industry and that is why the measure ultimately failed. “It's kind of brutal,” she added.

Yet big money doesn't always talk. The tobacco industry contributed millions to the election cycle in Missouri but was unable to sway voters to support a limited tobacco tax. In moves that confused the public, tobacco companies supported two different cigarette tax proposals while health advocacy groups opposed them.

Reynolds American donated $12 million to the campaign in support of Amendment 3, which proposed to phase in a 60-cent tax to Missouri's current

17-cent-per-pack tobacco tax by 2020. The $300 million generated annually from the tax would have gone to early childhood education.

A competing tobacco tax proposal was supported by smaller tobacco companies like XCaliber International and Cheyenne International. The tobacco groups contributed $4.8 million. The measure, on the ballot as Proposition A, called for a 23-cent tobacco tax to be phased in by 2021.

Bigger tobacco firms supported Amendment 3 because a provision of the law would have hurt their smaller rivals by implementing an additional 67-cent-per-pack tax on discount brands—on top of the 60-cent hike imposed on the major brands. The discount brands were left out of a 1998 tobacco lawsuit settlement.

Surprisingly, both the measures were opposed by the American Heart Association, the American Lung Association and the American Cancer Society Action Network, which argued neither tax was high enough to curb smoking rates. The tax increase “has to be significant enough to make consumers pause and think maybe it is really time for me to quit,” said Karen Englert, the American Heart Association's government relations director in Missouri.

James Harris, a campaign spokesman in support of Amendment 3, said the opposition from the health advocacy groups was “very disappointing.” Public town hall meetings were held to determine a tax voters would be willing to approve. A 60-cent tax was the most the public would allow, he said.

“Yes on Amendment 3” ads and social media platforms featured experts who discussed the importance of educating children early. Despite the money to reach voters, Amendment 3 was struck down. Proposition A was also rejected by voters.

The highly contentious election season probably hurt the passage of Amendment 3, Harris said. “It was difficult for people to approve a tax increase when you had Trump's anti-government, anti-tax rhetoric.”

When it came to soda, however, the public was more willing to support a tax. California voters in San Francisco, Albany and Oakland approved a penny-per-ounce tax on sugary beverages. Boulder, Colo. voters approved a 2-cent-per-ounce tax.

“The tide is turning,” said Larry Tramutola, a consultant for the campaigns in support of the California taxes.

The victories in the Bay Area were achieved even with $30 million from the beverage industry poured into opposing the taxes. In San Francisco alone, the beverage industry spent $19.3 million to defeat Proposition V. The support campaigns received about $20 million in contributions.

The beverage industry called the proposals a tax on grocery stores. The ads featured the owners of small grocery establishments concerned the tax would negatively affect their bottom line.

Yet the tactic didn't dissuade voters more concerned about the public health impact of sugary drinks. “It was the right message and the right issue, and clearly people got it,” Tramutola said.