Expertise Meets Politics

Efforts to Work with States

Over the past 20 years, state governments have emerged as critical players in health care. They have an important regulatory role, and as payers for medical care under Medicaid and other programs offering services for needy people, can affect the structure of the delivery system.

As states develop health policies, foundations can assist by providing resources for technical assistance, research, and analysis, and demonstration of new ideas. Foundations can also bring together individuals interested in state health policy to share ideas and experiences. The Robert Wood Johnson Foundation has supported more than 15 national programs to help states improve health policy, health financing and the delivery of health care services.

Beth Stevens, formerly a senior program officer at the Robert Wood Johnson Foundation, has managed evaluations of some of the key state programs supported by the Foundation. Lawrence Brown is a political scientist and professor of public health at Columbia University. He has followed and evaluated the Foundation's state policy activities for some time. In this chapter, they explore the question of what effect the Foundation's investments have had on health policy at the state level. It is a difficult question to answer, given complex state political environments and the indirect roles—such as improving information and understanding of options—that foundations play. The authors describe various Foundation-supported programs, examine the problems of working on health care improvement at the state level and offer suggestions for future approaches to state health policy development. At its core, however, this chapter is a case study of how the State Initiatives in Health Policy Program, which attempted to assist states in insurance and financing reform, unfolded in the periods just before and after the efforts at national health care reform during the first Clinton administration.

Since the failure of health reform, programs with states have come under attack by people who assert that foundations are imposing their own agendas and are controlling, rather than aiding, state governments. We believe these assertions are wrong, but they underscore the points made by Stevens and Brown that the process of policy development is highly political and that foundations can play only limited roles. Moreover, even in these limited roles, foundations are subject to attack.