Chapters of the American College of Surgeons (ACS) play a significant role in grassroots advocacy at the state level. With political gridlock in Washington, DC, it often falls to the states to address health care issues. In addition, the practice of medicine and surgery is regulated by state governments through professional licensure, establishment of standards for health care facilities, and so on.
Successful grassroots advocacy involves many strategic elements, perhaps most notably drawing together a strong, functional coalition of like-minded organizations to work for passage of legislation. We were able to achieve this goal in Georgia over the long term concerning the issue of coverage for bariatric surgery, and we hope the following story will inspire and motivate other ACS chapters in their own grassroots advocacy initiatives.
Roots of the problem
In 2011, due to state budget cuts, the Georgia Department of Community Health (DCH) abruptly discontinued coverage of bariatric surgery for members of the State Health Benefit Plan.* From that point on, Georgia surgeons were hard at work advocating for their patients by seeking reestablishment of this important treatment option for morbid obesity. Members of the Georgia Society of the ACS (GSACS) and the Georgia Chapter of the American Society of Metabolic and Bariatric Surgeons entered into a coalition with patients, the Obesity Action Coalition (OAC), the Georgia Hospital Association (GHA), and medical device makers. These stakeholders worked together to restore the bariatric surgery benefit.
In 2012, the coalition focused its efforts on restoring funding in the state budget, thereby having the bariatric surgery benefit reinstated. The coalition was successful, and the Georgia legislature allocated $1.75 million in the state budget to restore the benefit for fiscal year 2013. Unfortunately, Gov. Nathan Deal (R) vetoed the language designating the appropriation for restoration of bariatric surgery coverage.
Snatching victory from the jaws of defeat
Based on advice from the legislation’s champions in the capital, the coalition changed its strategy in 2013. The new goal was to achieve legislative relief by way of a pilot project to study the return on investment of the bariatric surgery benefit in the State Health Benefit Plan.* H.B. 511 was introduced and called for implementing a pilot program within the State Health Benefit Plan for coverage of 75 bariatric operations per year for two years, plus requisite follow-up care. During the 2013 legislative session, the Georgia House of Representative passed H.B. 511 with an overwhelming majority. However, the legislation was never called up for a vote in the Georgia Senate—not because of opposition to bariatric surgery, but because of fears that the legislation would be amended to include other, more contentious provisions.
Between the end of the 2013 Georgia legislative session and the beginning of the 2014 session, the coalition again approached the DCH and asked that the benefit be restored outright. That request was denied, so when legislators gathered at Georgia’s capitol in January of 2014, the coalition was there to greet them. Finally, after considerable advocacy efforts on the part of the coalition, H.B. 511 received final approval and was signed by Governor Deal in the spring of 2014. The pilot project is scheduled to begin in January 2015.†
While this effort will not be considered successful until the benefit is restored completely, the passage of H.B. 511 is worth celebrating. This achievement could not have been accomplished by any one member of the coalition.
For a coalition to be successful, communication is paramount. In Georgia, our coalition established a clearly defined goal and a strong commitment from all the stakeholders to stay focused on achievement of the goal. The strengths and weaknesses of each member of the coalition were considered in developing a strategy that prominently featured the core assets of the group. One of our greatest strengths was agreeing early on that it did not matter which organization took the lead or got the credit.
The OAC identified patients and advocates who made telephone calls to legislators, wrote testimonials, and submitted op-ed pieces to media outlets. Patients and surgeons testified before legislative committees, putting human faces to the value of bariatric surgery beyond the return on investment data. The GHA and surgeon advocates partnered to provide information, education, and testimony on the safety of the surgery and the outcomes. The medical industry members of the coalition provided a wealth of data on the success of pilot projects in other states and the return on investment for bariatric surgery. When faced with an obstacle, the coalition evaluated the situation and made a unified decision. The strength and ultimate success of the coalition was, and continues to be, its collective commitment to the goal.
As is true of many efforts at the state level, this initiative will take some time to complete; state legislatures rarely take immediate action to address a problem, even with a solution that seems obvious. Political factors usually come into play, slowing down—or, in some rare cases, speeding up—the process and requiring regular re-evaluation of advocacy strategies. The Georgia coalition remains unified and will continue to work toward the successful completion of the bariatric surgery pilot project and, ultimately, the restoration of bariatric surgery coverage for Georgia’s state employees.
*American Society for Metabolic and Bariatric Surgery. Georgia to cover bariatric surgery again: After dropping coverage in 2011, state signs on for pilot program. May 2014. Available at: http://connect.asmbs.org/may-2014-ga-surgery-coverage.html. Accessed October 1, 2014.
†Georgia Department of Community Health. State Health Benefit Plan. My 2015 SHBP decision guide. Available at: http://dch.georgia.gov/sites/dch.georgia.gov/files/42578_Active.pdf. Accessed October 9, 2011.