A Proposition for Change

Figure. Covers of mailers sent to voters in 2004

Children are not our future, as an old saying goes; they are our legacy. And we are failing them.

We like to think of our nation as “child friendly” but this is wishful thinking. We fail them in our educational institutions, our social services, our health systems, and in our families. Today's “high-risk” kids likely will mature with lasting physical and mental scars. What future faces the abused child? How will the son or daughter of addicted parents learn “normal”? Can the young female “cutter” soothe her own children later in life? Will the addicted teenager succeed in adulthood? What faces the fearful young man with schizophrenia whose symptoms have just begun? Community mental health centers (CMHCs) across the country face the daunting task of addressing these issues in an ever-increasing competition for service dollars.

A history of local support

Like many areas across the nation, our St. Louis, Missouri, bedroom community has seen massive population growth and an accompanying increase in behavioral health problems. We have acutely felt the stagnation of state and federal interest in behavioral healthcare. Thus, we decided to turn to our local community, where all successful ventures must begin, for help.

In 2002, Missouri CMHC directors successfully lobbied for legislation enabling counties to approve sales taxes for children's services. In 2004, Jefferson County passed a 1/8-cent sales tax. Few people expected our success. We did, as we had done it before. In 1986, more than 200 volunteers helped us pass a property tax (mil tax) for mental health services. At that time the Community Mental Health Fund Board (CMHFB) was created by the County Commission, which selected the entire board of our agency, Comtrea, to serve as the new CMHFB. Comtrea reorganized itself in accordance with the County Commission's directives in order to serve as the county agent for mental healthcare.

The 1/8-cent sales tax revenues also flow to the CMHFB, and we believe Comtrea is the only CMHC in the United States with both a dedicated property tax and a dedicated sales tax to fund its services. More than $5 million a year in tax funds provide care for people of all ages with mental, behavioral, and/or substance use problems.

Our strategy

We were successful because we understood how to be political. “All politics is local,” the old saying goes. With that in mind, in 2004 we began with certain assumptions about passing a sales tax in Jefferson County, Missouri:

• Taxes are not popular with anyone.

• The climate was not conducive to passage. We figured only about 19 to 22% of voters would initially be favorable to any tax issue.

• Negative voters (estimated between 28 and 33%) will turn out regardless of the issue, so counteracting this would require large voter turnout.

• A presidential election draws the largest number of voters.

• Children's issues engender sympathy.

• Comtrea has a great reputation in the community and enjoys broad political support.

With these assumptions in mind, I met with each of the three county commissioners. As the presiding commissioner was a Republican and the district commissioners were Democrats, their bipartisan support was crucial. The two district commissioners were up for reelection and took quite a risk endorsing a tax issue, yet all three placed children's needs above other concerns, unanimously placing “Proposition Healthy Kids” on the ballot without requiring a petition drive.

A carefully selected focus group developed a plan for passing the proposition. In early June 2004, the Comtrea Board adopted the plan, which included the following actions.

• We distributed flyers to voters as they left the August 2004 primary, asking them to remember Proposition Healthy Kids when they returned in November. We assumed primary voters would turn out for the fall election.

• We created a booklet (also placed on our Web site) that discussed in detail the need for the tax and what would be accomplished with its passage.

• We spoke before community and parent/teacher organizations, requesting their assistance or volunteer time—not money.

• We worked with a professional media consultant to develop two mailers sent to those who voted in the 2000 general election (figure).

• We met with the St. Louis Post-Dispatch's editorial committee and obtained its en-dorsement.

• We purchased 200 yard signs stating “Vote Yes: Proposition Healthy Kids,” which the Jefferson County Labor PAC helped to distribute.

• We sent letters requesting assistance to every church in the county. The faith community either supported the proposition or did not oppose it.

• We encouraged and received the support of the Jefferson County Counselor's Association.

• We approached school boards for their aid. In fact, the main factor in the proposition's passage appeared to be the support of the schools and school supporters, who saw the great benefits for children.

• We placed information slides about the proposition in movie theaters.

• We developed as much positive publicity as possible in the local media.

• 150 volunteers canvassed new subdivisions in a door-to-door campaign.

We spent $50,000 on the proposition. The steering committee believed a “word of mouth” effort would pass the issue, not throwing money at it. They were right, as the final vote reflected only a 44% negative response.

We performed a “plus-delta” review of the campaign about a month after the results were validated. We found that the initial plan had been effective despite the fact that there did not appear to be a strong community mandate for the effort. The wording of the proposition appeared to have gained us at least two percentage points and perhaps prevented some from voting against it. The support of both major political parties, as well as Libertarians' promise not to oppose the proposition, carried a great deal of weight.

The final results reinforced the fact that a well-thought and successfully implemented plan addressing a valid need can be successful. Many people with mental illness, behavioral issues, and substance use problems cannot effectively advocate for themselves. We, as their caregivers and advocates, must reach out for them in innovative ways.

Stephen F. Huss, PhD, is President and CEO of Comtrea, a community mental health center based in Jefferson County, Missouri. For its work with Proposition Healthy Kids, Comtrea was recognized last year with the National Council for Community Behavioral Healthcare's Excellence in Community Collaboration award. For more information, contact Dr. Huss at shuss@comtrea.org. Behavioral Healthcare 2008 November;28(11):10-11