1. Colorado Lessons Learned from our Mistakes and Successes! Emily Arell Colorado Consumer Health Initiative January 27, 2007 Families USA Health Action 2007 Washington, DC

2. Colorado Timeline 1992 TABOR (Taxpayer Bill of Rights) passed by voters in Colorado 2000 First attempt to pass tobacco tax in Colorado (effort fails) 2001 Recession begins, impact of fiscal restraints felt in Colorados health care programs 2004 Voters pass Amendment 35, Tobacco Tax, increasing health care access to over 90,000 Coloradans 2005 Voters pass Referendum C to suspend TABOR for 5 years 2009 5 year TABOR time out ends

3. Landscape in Colorado: Initiative state Often times the testing ground for conservative policies Colorado already had one of the leanest Medicaid programs in the country Colorado Voters: Believe in the bootstraps mentality Inherent mistrust of government and believe that government bureaucracy is inefficient Little to no understanding of tax law and budget Underestimate the number of government services they personally utilize (roads, etc) Focus on Government fraud and abuse

4. TABOR Douglas Bruce and other anti-tax crusaders Attempt to limit the growth of government Limits state local and municipal government at all levels

5. What do you think you are getting if you vote YES? Shall there be an amendment to the Colorado Constitution to require voter approval for certain state and local government tax revenue increases and debt; to restrict property, income, and other taxes; to limit the rate of increases in state and local government spending; to allow additional initiative and referendum elections; and to provide for the mailing of information to registered voters? Voters pass TABOR in 1992 with 54% of vote

6. TABOR-the nuts and bolts 4 major provisions 1.Voter approval of tax increases 2.Revenue limits –Formula: Population + inflation or 6% growth (whichever is less) –If revenue exceeds these limits, must refund excess to voters 3.Spending limits -- Ratcheting Effect 4.Limitations on tax options

7. TABOR-Impact on Public Programs Cuts to Medicaid Medicaid for legal immigrants Cuts to SCHIP (CHP+ in Colorado) Cap on CHP+ enrollment Cut access for CHP+ for pregnant moms Disability services created a wait list for services

8. TABOR Lessons learned from Colorado More of each state dollar is spent on Medicaid without expanding services Populations that could be served by Medicaid are not having their needs met because the state cannot afford to extend benefits to these groups Populations pitted against each other for funding Advocacy Groups have been forced to turn to ballot to raise funds for their programs Colorado does not have a rainy day fund

9. Why you dont want TABOR in your state 19922004 Low-income uninsured Children (CO) 16%32% Low-income uninsured children (Nation) 21%18% Low-income uninsured adults (CO) 31%46%

10. Colorado Voters Acknowledge TABOR is Flawed (2005) Referendum C –Bi-partisan legislative compromise –Allows the state to spend or save revenue it collects for 5 years –Revenue raised will fund three areas: Education, health services and roads. –Allows state services to rebound after recession –Does not result in new taxes –Colorado taxpayer with median income will give up less than $70 a year or.20 cents a day

11. Colorado voters pass 5 year TABOR time out Referendum C –Passes 52 % vs. 48% (2005) –Broad coalition-460 organizations endorse –Message to votersinvest in a brighter future Protect BASIC government services –Hard to quantify impact –What happens after 2009?

12. TABOR-coming to your state in the near future? Bad track record but continue to move into new states zealously 2005-primarily via legislation 2006-year of the initiative –Defeated in Maine (55% vs. 45%), Nebraska (70% vs. 30%), and Oregon (70% vs 30%) Colorado remains the ONLY state with TABOR Message– –TABOR did not work in Colorado message works no matter what sate you are in –Simply saying No to TABOR only goes so far

13. 2005 TABOR Summary Courtesy of Karen Lyons, Center on Budget and Policy Priorities

14. 2006 TABOR Summary Courtesy of Karen Lyons, Center on Budget and Policy Priorities

15. Trends in TABOR Tighten up Colorado plan –Override becoming more challenging 2/3 Leg plus voter approval –Only allow 1 year timeout (due to Ref C) Efforts have been unsuccessful due to: –Fraud (out of state circulators) –Insufficient signatures –Legal challenges –Single subject rule violation –Successful Advocacy and coalition efforts

16. Take Home Messages TABOR Avoid the TABOR fight If TABOR comes to your state, tell the Colorado horror story Long term, there is a real need to educate voters about the role government plays in their lives Coalition collaboration has been successful in fighting off TABOR

17. Colorado seeks alternate revenue source to fund health care Amendment 35 Tobacco Tax (2004) First successful healthcare effort in Colorado to raise taxes statewide since TABOR Raised tobacco tax from 20 cents/pack to 84 cents/pack Revenue expands health care programs and access

18. Lessons Learned from 2000 Failed effort in 2000 to pass Tobacco Tax (40% vs 60%) Strong opposition from Tobacco Industry ($5 million to defeat) Lessons Learned –The initiative focused too narrowly on tobacco cessation and not as a means to raise revenue for public programs –Polling showed: Health care link made sense to voters Tell voters where funds would be spent

19. Steering Committee starts meeting in 2002 Coalition effort broadens beyond anti-tobacco advocacy groups –Community Health Clinics –Childrens Hospital –Colorado Consumer Health Initiative –AARP –Colrado Childrens Campaign –AFLCIO and SEIU –American Heart Association –American Lung Association –American Cancer Society –Colorado Tobacco Education and Prevention Alliance

20. Guiding Principles 1. Money would be used to EXPAND access and funding for programs and not supplant existing funding 2. Impactnot an attempt to spread money thin to large # of programs 3. Politically viable 4. Maximize federal matching dollars 5. The people most impacted by tax will see benefit from expanded services

21. Where the Money Goes-46% Medicaid Expand Medicaid eligibility from 33% to 60 % FPL Restores Medicaid presumptive eligibility for pregnant moms (restoration to TABOR cut) Remove Medicaid asset test for Medicaid children Restore Medicaid coverage to legal immigrants (restoration to TABOR cut) CHP Expand CHP+ (SCHIP) eligibility from 185% to 200% FPL (relief for working families)

22. Where the Money Goes, part 2 Tobacco education and cessation (15%) Safety net clinics that serve the uninsured and medically indigent (19%) Prevention, detection for chronic diseases (15%) –Cancer –Cardiovascular –Pulmonary Remove wait list for HCBS and child extension waivers Funding earmarked for disparate populations –Rural –Communities of color

23. Opposition Some criticism that Am 35 is a regressive tax Independence Institute –Cheaper to let smokers die!!!!!!! Anticipate your opposition and mitigate –Municipal and county governments were nervous they would loose revenue with raise in tax Hold harmless clause 5% (generous) to counties

24. Coalition Building-You will need lots of Friends Citizens for a Healthier Colorado –Business –Faith –Colorado Non Profit Association –Focus on the Family –Hospitals, providers –SEIU and other labor groups –CoPIRG Over 100 organizations endorsed

25. The Initiative Process-start early #68,000 signatures needed to place on ballot Timeline---2 years $3 million and significant staff time dedicated

26. Ballot Language- Clear and Concise State taxes shall be increased $175 million annually through additional tobacco taxes imposed for health related purposes….to expand eligibility for and increase enrollment in the Childrens Basic Health Plan, to fund Comprehensive primary medical care through certain Colorado qualified providers, tobacco education programs, and prevention, early detection, and treatment of cancer and cardiovascular and pulmonary diseases……specifying that the appropriations of additional tobacco tax revenues shall be in addition to and not substituted for appropriations 64 Cent raise in tobacco tax (per pack) for total of 84 Cents (per pack)

27. Messaging-Learn it, love it and Repeat it! Saving money and saving lives Colorados rank: 3 rd lowest tobacco tax (above Virginia and Kentucky) Moderate tax increase that will make a big difference Smoking costs the state Raising the price of tobacco will protect generations of Colorados kids from tobacco and help smokers quit Constitutional amendment means money will be spent as promised This initiative is being supported by groups you know and trust

28. Opposition Tobacco Industry Independence Institute

29. Educating the electorate Voter education and outreach Literature drop Full time Communications Director Speakers Bureau---20 speakers

30. Over 90,000 Coloradans Gain Access to Healthcare Eric and Marc Stahlman gets off the HCBS wait list and access services in their home 2004: Voters approve Am 35 61 % vs. 38% Raises $175 million in revenue for health care

31. Our work is not Over Implementation dates varied from July 1, 2005 through July 1, 2006 Am 35 monitoring project –Are the funds going where we promised the voters? –Are sin taxes a long term strategy for funding state health care programs? –If the cessation efforts are successful, what will revenue source be in future?

32. What does it Take? Is your state ready to raise the tobacco tax? Resources---staff and financial ($3 million) Broad coalition involvement Not every state will have to go to the ballot What services will receive funding from the raised revenue?

33. Take Home Messages Tobacco Tax Consider raising a sin tax to fund health care programs in your state Dont give up if your first attempt to raise a tobacco tax fails Tie the tobacco tax to health care programs and tell the voters how the revenue will be spent The tobacco industry will not fight you if you are well organized early in the campaign

34. Contact Info Emily Arell Colorado Consumer Health Initiative 1536 Wynkoop St #101 Denver, CO 80206 (303) 839-1261 Emily@cohealthinitiative.org For more information on TABORs impact in Colorado: Carol Hedges Colorado Center on Law and Policy (303) 573-5699 X 306 chedgesc@cclponline.org