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This volume of The Robert Wood Johnson Foundation Anthology begins with three chapters that explore the Foundation's work over the years to expand health insurance coverage—much of it directed toward policy change. The fourth chapter examines the Foundation's efforts to affect public policies more generally, with emphasis on those that encourage healthy behaviors and lifestyles. Although many foundations shy away from an approach intended to influence policy, the Robert Wood Johnson Foundation has employed such an approach, and in no area more so than health insurance coverage.
There are many reasons that foundations avoid grantmaking intended to bring about policy change. Perhaps the most significant is the prohibition against lobbying. Even though foundations and their grantees are permitted to educate policy-makers about issues, develop issue-oriented communications campaigns, and support advocates favoring or opposing positions on specific issues, the mere proscription of lobbying and the fear that they might cross the line and run into trouble with the Internal Revenue Service keeps many foundations from funding policy work.
Adding to foundations' reluctance to fund policy work are other factors. Success—often defined in terms of new legislation or regulation—depends on economic, political, and social factors beyond the control of any single foundation, or, for that matter, any aggregation of foundations. Policy change usually takes a long time and requires a substantial commitment over many years. The likelihood of success is low, and even when such change does occur, the number of players involved makes it difficult to attribute it to any one of them. Furthermore, politics is a messy, highly partisan business. Entering the political trenches can force foundations to abandon the comfortable perch of only supporting objective, nonpartisan research and analysis.
Given these challenges, why has the Robert Wood Johnson Foundation chosen to invest so much of its money and credibility in trying to bring about policy change? The answer is simple: the potential payoff is so high. As James Marks, a senior vice president at the Foundation, and Joe Alper, a freelance journalist, write in Chapter Four of this volume, "While direct services grants…can improve the health of individuals and communities, grants to bring about changes in public policy have the potential to reach far greater numbers of people and create lasting improvements." Moreover, in the realm of health insurance specifically, policy reform is central to addressing the problem: unless policies are changed, health insurance coverage cannot be expanded widely.
Health insurance coverage will not, by itself, lead to better health outcomes for the U.S. population. It is, however, an essential step, and its importance is widely recognized in a country where nearly 18 percent of the people younger than 65 do not have health insurance and the number of uninsured is rising as fewer employers offer job-based coverage.
Not only is the need for health reform apparent, but it also has returned to the national agenda for the first time in 15 years. In the run-up to the 2008 presidential nomination, the Democratic candidates proposed universal or near-universal health insurance coverage. Republicans have taken a different approach, one that focuses less on universal insurance coverage and more on cutting costs and drastically reforming the system.
With the emergence of health insurance reform on both the national and state policy agendas, it is appropriate to look back at the Foundation’s efforts to expand health insurance coverage over the past 36 years.
The Evolution of the Robert Wood Johnson Foundation’s Work to Expand Coverage
When the Foundation began operating as a national philanthropy in 1972, health insurance expansion seemed to be just around the corner. Only seven years earlier, the health care landscape had changed dramatically with the passage of Medicare and Medicaid. Medicare ensured coverage for those 65 and older and for disabled people, and Medicaid covered poor people of all ages. In the early 1970s, Congress appeared to be poised to pass some form of national health insurance covering virtually all of the nation’s nonelderly population. Indeed, in 1974 President Richard Nixon said that national health insurance was “an idea whose time has come in America.” He proposed an employer mandate that would require businesses to insure their employees; labor supported a single-payer national health insurance proposal; Senator Edward Kennedy and Representative Wilbur Mills, two key congressional leaders, supported a compromise.
Responding to what they saw as the inevitability of national health reform, the Foundation’s trustees and staff focused on improving access to and the quality of medical care. From 1972 to 1976, the Foundation devoted nearly 75 percent of its expenditures to improving access to care (including the delivery of outpatient medical services and the training of health professionals to meet the expected increased demand) and about 15 percent to improving the quality of medical care. To increase the supply of primary care providers, for example, the Foundation funded programs to educate physicians and medical residents in primary care and to nurture the development of new midlevel professionals, such as nurse practitioners and physician assistants. To make services more widely available in underserved areas, the Foundation established freestanding clinics and hospital-based ambulatory care practices, such as the one in Reedsport, Ore., a small timber community, under the Rural Practice Project described by Lee Green in Chapter Five of this volume.
By the mid 1970s, the prospects for health insurance reform were dead—the victim of Watergate, the resignation of President Nixon, and a scandal involving Wilbur Mills. Even with hopes for national health insurance dashed, the problem of lack of access to care remained, and improving access to ambulatory care continued to be the Foundation's most important priority through the years of Jimmy Carter's presidency.
After the 1980 election, President Ronald Reagan emphasized different themes, such as lower taxes, smaller government, and medical cost containment, and devolved more responsibility for social programs to the states. During the early years of the Reagan administration, the Foundation's programming continued to emphasize access to care, but from 1982 on, it began to give priority to health care financing and cost containment as well. That year, the Foundation authorized the Community Programs for Affordable Health Care, which supported projects in 11 sites designed to lower medical costs, and the Program for Demonstrations and Research on Health Care Costs, a research effort that evolved into the Changes in Health Care Financing and Organization, or HCFO, which continues today and is the Foundation's longest-running research program. As the journalist Carolyn Newbergh observes in Chapter Two, HCFO has produced research on coverage, costs, and organization of health care, as well as on specific government programs such as Medicare and Medicaid. By the mid 1980s, the Foundation's funding of programs to expand access to care and to make health care more affordable were just about equal, each consuming roughly a third of the Foundation's grantmaking budget.
In the mid 1980s, the Foundation also began to look to the states as incubators of ideas to expand health insurance. In 1985, it funded the Health Care for the Uninsured program to test ways to provide health insurance to employees of small businesses. Starting in 1991, the Foundation funded State Initiatives in Health Care Reform, which continues today under the name of the State Coverage Initiative. This program provides grants and technical assistance to states planning to expand coverage, with the hope that successful models can be copied by other states or the federal government.
National health reform once again took center stage with the election of Bill Clinton as president in 1992. As the Clinton administration developed its health reform proposal, the Foundation funded a series of television broadcasts entitled "Conversations on Health," in which Hillary Clinton and members of the Clinton administration played prominent roles. As the Brown University political scientist James Morone notes in Chapter One, the Foundation was blindsided by the emerging political shift that led to conservative Republicans' capturing Congress in 1994, and it was criticized for appearing to support the Democratic health reform proposal.
After the failure of the Clinton health reform plan in 1994, the activity on health insurance coverage shifted largely to the states. The Foundation's next major initiative avoided national health care reform altogether and, rather, concentrated on taking advantage of legislation already in place. In 1997, the Foundation developed Covering Kids, a program to enroll eligible children in Medicaid in 13 states. Before the program even began, Congress enacted the State Children's Health Insurance Program (SCHIP) to expand insurance coverage of children from low-income families. As the journalist Irene Wielawski observes in Chapter Three, the Foundation, in response, expanded Covering Kids to include children eligible for SCHIP and Medicaid in all states and, as Congress expanded SCHIP to cover families, so did the Foundation with its successor program, Covering Kids & Families. Both programs incorporated a major communications campaign, Back to School, to let families know about a special hotline that they could call to enroll their children in Medicaid or SCHIP.
Maine, Massachusetts, and Vermont passed laws aimed at insuring virtually all residents. California came close to passing similar legislation in 2007. Other states have expanded coverage to specific populations, such as children, or have introduced bills to expand coverage and/or cut costs.
In addition to its programs supporting the efforts of states to expand coverage and enroll eligible children in public programs, beginning in 2003 the Foundation began to tiptoe back into the national arena with the first in a series of Cover the Uninsured Weeks, designed to raise awareness of the need to insure all Americans. Unlike "Conversations on Health," this major communications initiative involved a broad set of sponsors—including business, labor, and other foundations—and it avoided even the hint of partisanship. The sponsors of Cover the Uninsured Week were so diverse that they were referred to as the "strange bedfellows;" with additional Foundation support, many of these sponsors later agreed on a series of principles for expanding health insurance coverage. The Foundation also made grants to a variety of universities and think tanks to conduct research on health insurance and the uninsured. The Foundation-funded reports of the Institute of Medicine, for example, summarized the scientific consensus on why having health insurance matters. The reports were widely cited in the congressional debates on the reauthorization of SCHIP in 2007.
Today the Foundation is opportunistic in its approach to coverage, building on its past work and strengths. At the national level, the Foundation is helping to set the stage for health reform by providing information and venues for policy discussions. For example, a grant to the Bipartisan Policy Center is engaging four former Senate majority leaders—Howard Baker, Tom Daschle, Bob Dole, and George Mitchell—to help political leaders navigate the political waters of health reform. Additionally, the Foundation is continuing to support state efforts to expand coverage and to maximize enrollment in SCHIP and Medicaid.
Some Lessons from the Foundation's Work to Expand Coverage
In its grantmaking to expand health insurance coverage, the Foundation learned that policy change is difficult to bring about—especially if you are one of many players and not necessarily the most influential one—and that insofar as it involves legislation, policy change is subject to the caprices of politics. The Foundation also learned to be realistic in its expectations, even as it established high aspirations, and that it needed to recognize the limitations of philanthropy in obtaining policy change—especially in a sector that consumes $2 trillion a year, or 16 percent of the U.S. gross national product. It learned that a commitment to public policy change needs to be long-term, that it must take advantage of opportunities as they arise, and that its approach must be broad enough to appeal to policy-makers’ intellect (through data gathering and research) and emotions (through stories). It also learned that a wide-ranging approach—from research and policy analysis to grassroots advocacy and from communications campaigns to technical support—allows it to reach more policy levers, that adopting a bipartisan approach and collaborating with other foundations can be advantageous, and that it cannot forget the importance of implementing policy change once it occurs. Perhaps most important, the Foundation learned that it cannot waver from its goal of attaining health insurance coverage for virtually all Americans but that it must show flexibility in the means to reach the goal.
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