Grassroots Activism 101

No one is quite sure when the word draconian came to be the semiofficial modifier of the word cuts, when used in conjunction with the noun DRA. Mark Newton recalls hearing it often during the campaign to convince federal lawmakers that their Medicare cost-saving bill was a disaster in the making for radiology.

“From the government’s perspective, the DRA was a success—the cuts saved 12.7% on Medicare expenditures, and yet patient access to imaging services did not suffer. You take that, along with Medicare’s growing need for more control over spending, and you have plenty of incentive for Congress to want to contemplate further cuts.” --Mark Newton

Newton, CFO of a radiology group in Hudson Valley, New York, was a local leader in the effort to derail the DRA, and he worked hard at encouraging others to speak up, be heard, and make a difference. Ultimately, the forces favoring full implementation of the DRA prevailed over grassroots coalitions like Newton’s; his consisted of 40 other New York radiology practices and their thousands of patients, all opposed to the imaging-antagonistic mandates spawned in the nation’s capital.
Mark Newton Their efforts, however, were not in vain, for they proved instrumental in protecting imaging against additional proposed financial hits. The lesson: What Newton accomplished, anyone can. Varied Responses When the DRA first surfaced in late 2005, the ACR and other groups urged their members to get involved in organized bids to block the DRA. Newton’s practice, a 20-radiologist group with two imaging centers (formerly known as Dutchess Radiology Associates, but using the oddly coincidental name DRA Imaging PC at that time), took that call to action to heart. While Newton and his colleagues did all that the ACR asked of them, he could not help noticing the wide variation in participation among other practices in the region. “It seemed that one or two had become very active, while most of the others were apathetic—some a little, some a lot,” he recalls. “The reason they did little or nothing was that they assumed that their voices would not be heard, or that it would be pointless to try to change Congress’ mind.” In the course of attending local ACR meetings at which the DRA was discussed, Newton eventually learned that fellow member Kirk Lawson, administrative director of radiology at NYU Langone Medical Center, New York, New York, was likewise alarmed by the spotty response of the region’s imaging community to so potentially serious a threat to practice viability. Newton and Lawson compared notes and realized that they might be able to take up some of the slack, were they to begin working together as a team. “By combining efforts, we could have a bigger voice and maybe accomplish more,” Newton says. “It also seemed to me that our two practices, speaking out as one, would have more credibility. A way that DRA proponents tried to diminish us was by claiming that opposition to the measure came from just the isolated radiology practice here or there, and that we didn’t represent anybody’s interests other than our very own.” Another advantage Newton and Lawson recognized in working together was, Newton says, “We would be able to develop more creative approaches to eliminating obstacles and communicating our positions. Good ideas tend to emerge easier and faster when you put at least two heads together.” Newton and Lawson didn’t need a mind meld to appreciate that the grassroots effort that for which they were sowing seed could be a very powerful form of advocacy. “The reason that grassroots campaigns are so often effective is that they bring to your advocacy a combination of policy, constituent, and political activism,” Newton says. “This gives members of Congress something they very much want, which is feedback from their constituents so that they can know how best to please the voters back home. It also gives members of Congress opportunities to interact more directly and personally with those constituents,” the better to communicate reelection messages. Waging a grassroots campaign can entail a few or many steps, depending on one’s level of commitment to the cause (and availability of time and resources). Newton and Lawson readily acknowledged their own limitations, especially inasmuch as they were political neophytes. Their main source of guidance, as rookies, was the book Our Iceberg Is Melting by Kotter et al.1 “It provided a great framework for understanding how to create change,” Newton says. Pointers culled from the book that Newton and Lawson found useful include these:

• create a sense of urgency to shake allies, supporters, and foot soldiers from their apathy and to overcome inertia;
• build a core team to provide the necessary leadership;
• create a sensible vision that supporters can rally behind and that skeptics (such as lawmakers) can embrace;
• celebrate even the smallest victories to keep enthusiasm and morale high among the rank and file; and
• never let up pressure until the goal has been achieved.

As helpful as the book was, however, much of what Newton and Lawson accomplished came about purely through trial and error. “We discovered that the single most effective tactic—at least for us, in our grassroots campaign—was asking patients to sign a petition,” Newton says. The petition statement itself was only about 100 words long. It implored members of Congress to reject the DRA’s cuts and to vote, instead, for the Access to Medical Imaging Act, a radiology-friendly alternative being floated at the time. This message was printed at the top of a sheet of letter-sized paper. Below were spaces for signatories to write their names and general location information. Multiple copies of the unsigned petitions were produced and set out at the reception desks of each radiology department office and imaging center operated by Newton’s and Lawson’s respective groups, as well as at those of other practices that had joined the campaign. “Receptionists were instructed to make each arriving patient aware of the petition and then to invite him or her to sign it,” Newton says. “We also posted a note in our waiting rooms explaining the DRA and giving reasons why signing our petition was so important.” Patients generally were happy to participate; few objected outright. When all was said and done, more than 20,000 signatures were collected. These were eventually delivered, in person, to Congress. Newton says, “It was very impressive to see the accumulated petition sheets on top of a hearing-room table. We had stack after stack of them, around 8 to 10 inches thick.” To be truly successful, it was necessary to educate receptionists and other staffers about the DRA so that they could give informed answers to patients when asked about the petition drive. With petitions, timing is everything. “Congress received our petition about nine months after we started asking patients to write letters and send emails of DRA opposition to their representatives in Washington,” Newton says, still marveling at how accommodating some politicians can be if the voter heat is turned up long enough. A Matter of Awareness Even with the success of the petition drive and the letter-writing campaign that preceded it, Newton, at times, felt that he was swimming against the current of a powerful river. “We met enough resistance to leave us discouraged,” he says. “To make matters worse, while we were trying to reverse the DRA, Congress was busy introducing other bills to cut imaging reimbursement further still.” Bills revising the State Children’s Health Insurance Program (SCHIP) and the Children’s Health and Medicare Protection Act (CHAMP) were being considered. The grassroots campaigners held on and kept plodding ahead, regardless. SCHIP and CHAMP legislation passed, but the provisions cutting radiology reimbursement were removed, thanks to the support of lawmakers who were influenced by petitions, letters, and face-to-face encounters with constituents. There was, of course, the disappointment of being unable to rally enough opposition to counteract the DRA with the Access to Medicare Imaging Act. Nonetheless, Newton believes that a case can be made that the grassroots activism that he helped spark was productive for the future. “We succeeded, in the sense that lawmakers now are more aware than they were at the start of all this about the harmful impact cuts can have on imaging—and about how voters feel on this issue,” he says. “Because of our efforts, I think there is now a greater reluctance on the part of Congress to adopt legislation that hurts imaging.” Still a Target There is reluctance in Congress, but there is still willingness to try. According to Newton, imaging remains a target. “From the government’s perspective, the DRA was a success—the cuts saved 12.7% on Medicare expenditures, and yet patient access to imaging services did not suffer,” he says. “You take that, along with Medicare’s growing need for more control over spending, and you have plenty of incentive for Congress to want to contemplate further cuts.” Newton remains positive, though. “Having participated in a grassroots campaign, I feel pretty confident about our ability to mobilize people, if and when necessary,” he says. “In 2008, there wasn’t much in the way of imaging-harmful legislation proposed. It was a quiet year, but we can pick up where we left off because of what we now have in place—40 participating practices and their patients who are willing to stand up and be heard.”