A Statewide Conversation on Health Care Reform Policy

Nearly five million Californians live without health insurance, and millions of others struggle with skyrocketing costs and the threat of losing their own coverage. To address this growing crisis, Governor Arnold Schwarzenegger declared 2007 the “year of health care reform” in California.

Assembly Speak Fabian Nunez and Governor Arnold schwarzenegger at a table during CaliforniaSpeaksAs state leaders considered competing reform proposals, thousands of Californians came together in an unprecedented statewide conversation to ensure that the public had a voice in shaping the state’s health care policy.

Independent evaluations show that participants stayed involved in the issue, policymakers valued the process and the resulting health care reform legislation reflected ¾ of the public’s priorities identified during CaliforniaSpeaks.

Reforming California’s Health Care System

While California spends almost $2 billion each year on health care, the state struggles to provide adequate care to all. At any given time, nearly five million state residents live without health insurance. The majority of those with health insurance believe their coverage does not meet their needs, with 75 percent saying they would not be able to handle the costs of a major illness or injury.

California Governor Arnold Schwarzenegger declared 2007 the “year of health care and several state leaders dedicated themselves to addressing this crisis. The lawmakers introduced a range of proposals that represented different approaches to reforming the state’s health care system.

To ensure that the California public had a real voice in the reform process, six local health care foundations invited the national nonprofit AmericaSpeaks to facilitate a statewide town meeting to weigh in on the reforms being considered by state leaders.

The level of participant support for all of the proposed changes varied, depending on the various conditions that were generated by the group discussion. There was at least one condition under which a majority of participants would be supportive of enactment for each proposed change.

CaliforniaSpeaks: A Truly Statewide Conversation

Two participants at a table discussingCaliforniaSpeaks brought together nearly 3,500 Californians on August 11, 2007, for an all-day, non-partisan conversation on health care reform.

Participants from every walk of life joined simultaneous town meetings in Humboldt County, Sacramento, Oakland, Fresno, San Luis Obispo, Los Angeles, Riverside and San Diego, all linked together by satellite technology. Using AmericaSpeaks’ 21st Century Town Meeting® method, diverse groups participated in roundtable discussions that were supported by professional facilitators. Groupware computers and keypad technology enabled ideas to be captured live and prioritized by all participants at the eight meeting sites.

State Law Makers Participate

State lawmakers joined participants at the meeting, including Governor Schwarzenegger, Senate President Pro Tem Don Perata, Assembly Speaker Fabian Núñez, and Assembly Republican Leader Mike Villines. Each confirmed that health care reform was an urgent priority for California and restated a commitment to legislative action.

Real Health Care Reform Choices

CaliforniaSpeaks worked with state and national experts, in
cooperation with state leaders, to develop non-partisan and accessible discussion materials to put real choices before the public. During the day, participants discussed and then voted on six key health care reform topics:

•  Employer Mandate
•  Expansion of Public Subsidies and Programs
•  Changes to Insurers (guaranteed issue and cap on profits)
•  Individual Mandate
•  Government-Based system (a.k.a. Single Payer)
•  Cost Controls

Key Conditions for Reform Options

Participants were asked to identify the conditions that would need to be in place in order to support major policy reforms being considered by state leaders. Examples of measures receiving the greatest support are:

  • 63 percent would support expanding  government-sponsored health coverage for  low- and middle-income Californians if it included provisions for wellness and prevention.
  • 59 percent would support “guaranteed issue” requiring insurers   to provide coverage to people regardless of medical condition if     here is sufficient accountability and oversight to make sure that all are actually covered.
  • 55 percent would support an “individual mandate” requiring all Californians to have health insurance if there is an adequate standard for quality care.
  • 96 percent of participants agreed that it was important to control costs.  This was critically important to two-thirds of participants.

The Outcome: A Public Mandate for Change

CaliforniaSpeaks participants emphatically called for reform. Across all eight meeting locations, 82 percent of participants said that the state’s health care system required major change, and 86 percent said it was important for reform to pass by year’s end.

Addressing a key concern for decision makers, 84 percent of all
participants said they were at least “somewhat willing” to share financial responsibility for reform,
with a full two thirds saying they were “willing”or “very willing.”

Public Remains Committed

After the event, participants remained committed in their call for health care reform, writing letters to the editor and sending e-mails to their representatives. Throughout the month following the meeting, CaliforniaSpeaks participants and organizers met with key legislators and staff in their district offices to present town meeting results.

Legislative Results

In mid-September, Governor Schwarzenegger called a special legislative session specifically to address health care reform. The result was a compromise health care reform bill, AB 1X1, which was passed in December 2007 by the California State Assembly with bi-partisan support from the Governor and Assembly Speaker. The announcement of a $14 billion budget deficit for the state stalled the legislation in the Senate. The bill ultimately failed to pass out of the Senate Health Committee after a legislative analysis questioned the bill’s financial risk.

Public Impacts of CaliforniaSpeaks

Three independent evaluations assessed the impact of the CaliforniaSpeaks statewide conversation, on participants, the policy making process and policy makers themselves.


Surveys of CaliforniaSpeaks participants found significant impacts compared to a control group. Participants were more positive about their attitudes about state government as a result of the event and had a greater belief in their own ability to be heard and make a difference. CaliforniaSpeaks participants were significantly more likely to take political action on health care – such as volunteering with a group, attending public meetings and contacting the media – compared to those who did not attend.

After the event, over 40% of participants contacted a public official about health care reform.


Policymakers hailed CaliforniaSpeaks as a successful event that brought in fresh public perspectives and generated a sense of urgency for bi-partisan change. The interviewed policy leaders pointed to key elements that helped build momentum, like the size of the convening, diversity of the participants, and how the technology allowed for multiple locations to have “direct” public participation with immediate results.  Policymakers welcomed this kind of event to be conducted again in California, and recommend it for early stages of the policymaking process.

Policy Outcomes

The CaliforniaSpeaks process generated public priorities on values to guide health care reform as well as conditions of support for specific policy priorities. A comparison of these priorities with the evolution of the proposed health reform bills show that reform moved closer to CaliforniaSpeaks priorities on ¾ of issues in debate. In fact, on all of the values and most of the policy options under active discussion by the full legislature, the legislation evolved to more clearly reflect the public’s priorities.

“Reform legislation moved closer to CaliforniaSpeaks priorities on ¾ of the debate.”