Increasing access to health care has been a goal of the Robert Wood Johnson Foundation since its very beginning. In Volume IX of the Anthology, Robert Rosenblatt reviewed the 30-plus-year history of the Robert Wood Johnson Foundation's efforts to expand health insurance coverage to all Americans and concluded that the Foundation's initiatives had oscillated between trying to bring about major change at the national level and working with states and communities to find ways to insure people locally. The Communities in Charge program is an example of the latter approach; it supported 14 communities' efforts to expand insurance coverage within their limited geographic area.
As Mary Nakashian observes in this chapter, the Communities in Charge grantees ran into many obstacles. These ranged from expected sources of revenue drying up to onerous insurance regulations, and from lack of administrative know-how to September 11th derailing planned activities. As the program unfolded, the communities showed a great deal of ingenuity in meeting the challenges, even if it meant deviating from their original plans. Though the number of people who obtained coverage under the program was disappointing, some of the sites developed strategies that could—and are—being replicated. Communities in Charge and other programs that look to generate local solutions for expanding insurance coverage raise the question of whether efforts to address lack of insurance coverage are best done at the community, state, or federal level, or some combination of the three.