| Introduction
Editors' Introduction By
Stephen L. Isaacs and James R. Knickman
When Gen. Robert Wood Johnson, the former chairman of Johnson
& Johnson and head of Franklin D. Roosevelt's effort to
mobilize small business in support of the war effort, died,
in 1968, he left the bulk of his billion-dollar estate to
a small foundation bearing his name. At that time, The Robert
Wood Johnson Foundation gave grants within the state of New
Jersey, primarily in the New Brunswick area. When the estate
was settled, in 1972, The Robert Wood Johnson Foundation was
transformed into a major national philanthropy. Today, with
assets of more than $5 billion, it is one of the nation's
largest foundations.
Describing the mission of the Foundation is deceptively simple:
to improve the health and health care of all Americans. To
fulfill that mission, the Foundation provides grants that
further one of three goals articulated in 1991:
- .
From its earliest days, the Foundation zeroed in on access,
particularly access to primary care. Initially, this emphasis
was based on the assumption (an incorrect one, as it turned
out) that national health insurance was just around the
corner and that the supply of primary health services would
not meet the demand that health care reform would generate.
Early grants focused on expanding the availability of emergency
medical services, developing perinatal care networks, and
increasing the supply of generalist physicians and other
health practitioners.
In the 1980s and 1990s, the Foundation emphasized access
for underserved and vulnerable populations, such as residents
of inner cities and rural areas, minorities, individuals
with chronic illnesses, and indigent and uninsured
individuals. It launched programs to encourage minorities
to become physicians, as well as demonstrations to show
innovative ways of providing services.
Current initiatives directed to improving access to health
care include grants to encourage reform efforts that expand
health insurance coverage, support of local efforts encouraging
practicing physicians to volunteer their services to needy
individuals, and establishment of a center tracking how
the changing health care markets in sixty communities affect
the health and health care of local residents.
- The Foundation's concern
about chronic illness dates back at least to 1982, when
it announced a goal of helping people maintain or regain
maximum attainable function in their daily lives. Beginning
in 1988, the Foundation targeted medical and social systems
of care for people with specific chronic illnesses. Since
then, a series of grants has provided support to local agencies
and communities to experiment with ideas to better coordinate
services for people with chronic illnesses. The Foundation
has financed initiatives such as the On Lok program in San
Francisco and its successors, which provided funding to
single agencies offering the full range of services needed
by frail elderly persons and others with chronic conditions.
Currently, the Foundation is in the process of awarding
grants to eight hundred interfaith religious coalitions
to create programs encouraging volunteers to assist chronically
ill members of their communities. Additionally, grant programs
are attempting to improve services to individuals at the
end of life and to develop better service systems under
managed care for people with chronic conditions. On the
analysis side, the Foundation has studies aimed at better
understanding the needs of the chronically ill and has published
Chronic Care in America,a chartbook outlining the
dimensions of chronic illness in America and the challenges
facing people with chronic conditions.1
- The Foundation's
mission has always emphasized improvement of health
and health care. However, the Foundation's targeting of
substance abuse as a key concern in 1991 was the first time
it had given such high priority to an area largely outside
traditional health care services. In support of this goal,
the Foundation has focused primarily on strategies to reduce
demand for tobacco, alcohol, and illicit drugs. A flagship
initiative, the Fighting Back Program, has supported community-based
endeavors in fourteen communities that bring together local
forces attempting to reduce substance abuse.
The Foundation has given special attention to keeping young
people from beginning to smoke, drink, or use illicit substances.
A $20 million grant was recently awarded to the Center for
Tobacco-Free Kids to make the public more aware of the importance
of curtailing the availability of tobacco products for young
people. The Smokeless States Initiative funds statewide
coalitions to reduce access to tobacco products. A peer-reviewed,
investigator-initiated grant program is funding research
on how public policy could better combat the damage caused
by substance abuse.
In 1996, the Foundation awarded a total of $267 million in
support of programs to advance these three goals. Twenty-eight
percent ($76 million) of the funds were for programs to advance
the Foundation's access goal, 14 percent ($38 million) to
advance its chronic care goal, and 39 percent ($103 million)
to advance its substance-abuse goal. In addition, it awarded
$36 million for programs aimed at finding ways to contain
the rising cost of health care, a topic that has also been
of importance to the Foundation, and $14 million for other
programs, primarily ones carried out in the New Brunswick,
New Jersey, area.
Another way to describe what the Foundation does is to look
at the strategies used in furthering its goals. In 1996, 31
percent of its grant funds were awarded for demonstration
projects, 15 percent for education and training, 24 percent
for research and policy analysis, and 20 percent to communications.
The remaining 10 percent went to evaluations, conferences,
technical assistance, and other programmatic uses.
Although the Foundation's resources are clearly substantial,
they must be placed in the context of a nation that spends
more than a trillion dollars annually on health care.
Given the relatively small contribution of the Foundation,
its ability to improve health and health care depends on the
strength of the ideas it funds, the quality of its programs
and grantees, and the ability to learn from the experiences
of its grantees and transmit this information widely.
The Foundation therefore places great emphasis on evaluating
its major national programs and having results reported in
journal articles, monographs, newsletters, audiovisual materials,
and conference presentations.
To Improve Health and Health Care, 1997 builds on
the Foundation's traditional means of sharing information
and goes beyond them. It provides an in-depth look at some
of the Foundation's programs--warts and all--by those who
know them best. It is intended to complement the Foundation's
Annual Report and its newsletter, Advances,
by offering a deeper analysis that is, we hope, more readable
than most journal articles.
It is not, however, a substitute for the detailed presentation
of findings about specific programs that have, in many cases,
been published in academic journals. The journal articles
cited in this book are mainly directed at the specialist with
an interest in a given area. By contrast, To Improve Health
and Health Care, 1997 focuses more on informed assessments
of the Foundation's strategies and on the larger lessons learned
from the programs presented in these pages.
In any single volume, we can examine only a small sample
of the Foundation's work. In 1996 alone, it funded 870 different
programs, and over two thousand grants were active. Choices
had to be made about which programs to present in this book.
The chapter subjects were selected on the basis of whether
a recent evaluation had been done, whether a program was sufficiently
far along to merit inclusion, and whether the findings would
advance knowledge in the field.
To Improve Health and Health Care, 1997 is organized
around three major subject areas: access to health care services,
the changing health care system, and the Foundation's efforts
to improve services for vulnerable groups. In many cases,
these categories intertwine with one another. For example,
a study of services for disabled people in Springfield, Massachusetts,
ultimately has to do with the first two subject areas, access
to care and how care is affected by changes in the system.
Access to Health Care Services
The first three chapters concern access to health care services.
In Chapter One, "Reach Out:
Physicians' Initiative to Expand Care to Underserved Americans,"
the program's evaluator, journalist Irene Wielawski, chronicles
how committed physicians from Tallahassee to Sacramento have
mobilized their colleagues on behalf of the uninsured. She
observes that, ironically, this is happening just as the commercialization
of the health care system is dampening the spirit of volunteerism
the program seeks to channel.
As one way of increasing access to health care services,
the Foundation funded programs to improve the health care
workforce. In Chapter Two, "Improving
the Health Care Workforce: Perspectives from Twenty-Four Years'
Experience," the Foundation's president, Steven Schroeder,
its executive vice president, Lewis Sandy, and an outside
analyst, Stephen Isaacs, examine the Foundation's workforce
efforts over nearly a quarter century. They cite both successes
and failures; based on the experiences to date, they offer
guidance for future workforce programs.
Much of what we know about access to care comes from four
Foundation-funded surveys conducted between 1976 and 1994.
These surveys build a solid base of reliable information upon
which policy makers can act. In the third chapter, "A
Review of the National Access-to-Care Surveys," Project
HOPE policy analysts Marc Berk and Claudia Schur offer an
inside perspective first on how researchers met some of the
methodological challenges in conducting these surveys and
second on the substance of the surveys and their importance
for public policy.
The Changing Health Care System
As the three chapters in the second section make clear, access
to care is affected by changes in the health care system--particularly
the sweep of managed care, the rise of for-profit health systems,
increased concern with cost containment, and the shift of
services from the federal to state governments. To gain a
better understanding of the system and to try to improve it,
the Foundation supported a number of initiatives, three of
which are examined here.
In Chapter Four, "Expertise
Meets Politics: Efforts to Work with States," Beth
Stevens, Foundation senior program officer, and Prof. Lawrence
Brown of Columbia University discuss lessons from a national
program that provided grants to states to test different models
of health care reform. The authors stress that foundations,
which view their work as apolitical, must always be aware
that policy change is ultimately influenced by politics and
is likely to stir local rivalries, engender conflicts, and
become messy and partisan.
In Chapter Five, "The Media
and Change in Health Systems," Marc Kaplan, senior
communications officer at the Foundation, and Mark Goldberg,
distinguished fellow at the Yale University School of Management,
report on a series of media briefings they organized to help
journalists understand the changing health care system. Given
the importance of the media, the authors conclude with a series
of tips on how health professionals can better explain to
journalists the forces now driving health care.
One of the most dramatic of these forces is the drive to
reduce costs, or at least slow their rate of increase. In
the 1980s and early 1990s, the public perception was that
malpractice lawsuits resulting in excessive awards by easily
swayed juries were driving physicians out of medical practice
and adding billions to the nation's health care bill. Through
a series of grants, the Foundation sought to discover the
gravity of the malpractice situation, investigate its root
causes, and explore alternatives for resolving disputes between
patients and physicians. The results are summarized in Chapter
Six, "Addressing the Problem
of Medical Malpractice," by health policy analyst
Joel Cantor and his colleagues.
Vulnerable Populations
The changing health care system and the political policies
jeopardizing the safety net pose a threat to the nation's
most vulnerable populations, who are the subject of the final
section of the book. While The Robert Wood Johnson Foundation
strives to improve the health and health care of all
Americans, it has devoted greatest attention to those who
are especially vulnerable: individuals who are disabled, indigent,
and uninsured; seniors; children; and people with AIDS.
In Springfield, Massachusetts, Brown University professors
Susan Allen and Vincent Mor surveyed the health and social
services available to disabled adults. Chapter Seven, "Unmet
Need in the Community: The Springfield Study," describes
an all-too-typical situation where services are characterized
by gaps, limitations, lack of continuity, and poor coordination.
Finding that many disabled people lack services and money
to meet anything more than their basic needs, the authors
conclude that "the status quo doesn't work."
SUPPORT (an acronym for Study to Understand Prognoses and
Preferences for Outcomes and Risks of Treatments) was a multiyear
project that examined how decisions were made by and for gravely
ill, hospitalized patients facing death. The results of the
study--especially the finding that physicians did not understand
patients' preferences--were widely reported in the media.
In Chapter Eight, "Unexpected
Returns: Insights from SUPPORT," George Washington
University professor Joanne Lynn, who codirected the study,
reflects upon the ramifications of the largest study of dying
people ever conducted in this country.
The Foundation has consistently supported programs designed
to improve children's health. One program, All Kids Count,
is now a collaborative effort with four other foundations
and the U.S. Centers for Disease Control and Prevention to
develop systems to track immunizations of preschool children.
In Chapter Nine, "Developing
Child Immunization Registries: The All Kids Count Program,"
University of North Carolina health systems analyst Gordon
DeFriese and his colleagues share early results of an evaluation
of this program. They discuss the constraints to maintaining
computerized immunization registries and offer suggestions
to a nation poised to develop extensive state and local immunization
registry systems.
In 1990, the Foundation, in collaboration with the U.S. Department
of Housing and Urban Development, launched a nine-city demonstration
project to help homeless families obtain HUD-supported housing
and find social services. In Chapter Ten, "The
Homeless Families Program: A Summary of Key Findings,"
Vanderbilt University health policy researcher Debra Rog and
Foundation senior program officer Marjorie Gutman explain
how the complexity and fragmentation of service systems, combined
with the many deeply rooted needs of homeless families, hamper
efforts such as these to bring about true change.
The AIDS epidemic justified research outside of the normal
purview of the Foundation: a survey of Americans' sexual behavior
and practices. Promised federal government funding for the
study was withdrawn because the research was viewed as too
controversial. Robert Michael of the University of Chicago
and his colleagues then approached the Foundation, which became
the first of several foundations to fund this groundbreaking
research. The National Health and Social Life Survey received
national media attention and was the basis for two books and
many scholarly articles. In the final chapter, "The
National Health and Social Life Survey: Public Health Findings
and Their Implications," the survey's codirector,
Robert Michael, pulls together the public health implications
of the survey.
As managed care and commercial enterprise continue to transform
health care; government budgets for social services are reduced;
an aging population suffers more from chronic than acute illnesses;
and unhealthy behaviors, including substance abuse, create
serious social and medical problems, those concerned with
health and health care face important challenges. To Improve
Health and Health Care, 1997 recounts how one foundation
is attempting to meet these challenges. We hope that it proves
useful to those working to improve the health care system
as well as those trying to understand and navigate it.
| Princeton, New Jersey
May 1997 |
STEPHEN L. ISAACS
JAMES R. KNICKMAN |
Endnote
1. C. Hoffman and D. Rice, Chronic Care
in America: A 21st Century Challenge (Princeton, N.J.:
The Robert Wood Johnson Foundation, 1996).(return
to article)
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