"The uneven availability of continuing medical care of acceptable quality is one of the most serious problems we face today. We need to better provide health services of the right kind, at the right time, to those who need it. Therefore, in its initial years, the Foundation will try to identify and encourage efforts to expand and improve the delivery of primary, frontline care." These words, written in 1972 by David Rogers, the first president of The Robert Wood Johnson Foundation, for the Foundation's first Annual Report, still resonate today.

Despite spending more than a trillion dollars on health care every year in the United States, more than 43 million Americans are still without health insurance, up from 31 million in 1987. Ten million children are uninsured. But the lack of health insurance is only part of this dismal picture. People who are poor, lower class, minority, or who live in inner cities or rural areas continue to have trouble getting medical services from a system that has become less, rather than more, responsive to their needs. Managed care may cut costs, but often at the expense of services and avoiding people with chronic diseases and other costly conditions.

Given the nearly intractable nature of the problem, the "initial years" Rogers referred to in the 1972 Annual Report have lasted three decades. Improving access to medical care not only remains a Foundation priority today but also is the one goal that has remained constant throughout the life of the Foundation. Reflecting this priority, access to care has commanded more space than any other topic in The Robert Wood Johnson Foundation Anthology series. Fourteen chapters on it have appeared in the five volumes of the Anthology. These chapters offer a perspective on how the nation's fifth-largest foundation has tried to improve access to care and, to a limited extent, what has resulted from its efforts. They reveal that, despite what appears at first glance to be a piecemeal way of doing business, the Foundation has taken five complementary approaches to addressing a problem that has commanded its attention for nearly 30 years.

The first approach: Fund research, particularly survey research, in order to gain a better understanding of the issue and its ramifications

Just a few years after its debut as a national philanthropic organization, the Foundation funded the first of four access-to-care surveys.¹ The findings from these surveys, conducted between 1976 and 1994, provided much of what was known about access, or lack of access, during that period. These surveys were followed, in 1995, by a large multi-year "health tracking" initiative designed to understand the changes in the health care system and their effects. For this initiative, the Foundation established the Center for Studying Health System Change, which conducts surveys in 60 communities every two years to find out, among other things, how managed care is affecting people's access to medical services.

This survey research has been supplemented by other quantitative research, much of which is conducted under the auspices of the Health Care Financing and Organization program, and, less frequently, by qualitative research such as that done by Susan Allen and Vincent Mor. Their study of the availability of services for chronically ill people living in Springfield, Massachusetts, concluded that the people most in need do not have access to even the most basic medical and social services.²

Over the years, the Foundation-funded research furnished "hard, reliable information on access to medical care."³It helped set the terms for debates about health policy and influenced the way that some policy makers and others thought about it. It is not clear, however, whether research has had an impact on policy, which may be driven more by ideology than by objective information.⁴

The second approach: Train and nurture leaders who can become "leaders in their home institutions, professional societies, and state and federal government."⁵

The Foundation has done this through a series of fellowship programs, directed mainly toward physicians. Two of them-The Health Policy Fellowships Program and the Clinical Scholars Program-have been in operation for nearly three decades. The Health Policy Fellowships Program sends six mid-career health professionals to Washington, D.C., to work for a senator, a representative, or a congressional committee. Its original goals, dating to 1973, were nothing short of preparing doctors for senior policy making positions in government and changing the face of academic medical institutions.⁶The Clinical Scholars Program, considered by many to be the Foundation's flagship program, trains physicians in the social sciences and other fields outside their areas of clinical expertise in order to give them the breadth of knowledge they will need as they assume leadership roles.⁷ Nearly 900 physicians have graduated from the program.

A more direct approach trained leaders of health professions whose members provide care to underserved people. Generalist medicine was one target. To develop a nucleus of leaders in general medicine (and to increase the credibility of generalist medicine in academic medical centers), the Foundation funded, in the 1970s, a series of primary care fellowship programs and residencies for general internists and general pediatricians. In 1991, it launched the Generalist Physician Initiative and two related programs intended to increase the attractiveness of primary care as a career choice for young physicians.⁸ Nurse practitioners, thought to be a potential source of care for people living in rural areas and inner cities, were another target. To develop this field, the Foundation funded, between 1977 and 1991, the Nurse Faculty Fellows program and the Clinical Nurse Scholars Program. The nurses trained under these programs became the leaders who gave credibility to the relatively new field of advanced practice nursing.⁹ Minority physicians, too, have been a target group. Since the 1980s, the Minority Medical Faculty Development Program has offered postdoctoral research fellowships to minority faculty members in non-minority medical schools and summer enrichment programs for minority college students interested in medical careers.¹⁰

Although these programs, with results that are not seen for many years, are expensive, often invisible to trustees and staff, and difficult to evaluate, they are considered to be a productive long-term investment. Writing in the 1998-1999 Anthology, Lewis Sandy and Richard Reynolds concluded that supporting promising young people through fellowship programs "may be a more effective institutional change strategy than direct institutional grants."¹¹

The third approach: Support and assist organizations with the potential to improve access to care.

These organizations might be professional societies. For example, the Foundation funded the creation and early activities of societies of nurse-practitioners and generalist internists. Or they might be research, teaching, and practice institutions, such as academic medical centers, which were considered the key to reversing the stampede of medical students into sub-specialties. Or service delivery organizations. The Foundation's early support of health maintenance organizations, dating back to a grant to the Harvard Community Health Plan in the early 1970s, was aimed at meeting "the nation's need to assure access, control costs, and improve quality."¹²

In some cases, the Foundation has supported government organizations. The State Initiatives in Health Care Reform, begun in 1991, aided states that were exploring options for health reform. The states used the funds to convene commissions and hold conferences, to hire experts, to carry out research, and to hire staff. On a federal level, during the debate over health reform in the 1990s, both current and past Health Policy Fellows were called upon to assist senators and representatives, and to serve on health reform commissions.

The concept behind supporting government organizations is to help bring about policy change, albeit indirectly. This also has a potential down side. As Beth Stevens and Larry Brown noted in the 1997 Anthology, effective policy change requires a knowledge of, and perhaps an involvement in, the messy business of partisan politics-something foundations have not generally shown an aptitude for.¹³ And foundations that do get involved in governmental policy matters-even if they are attempting only to improve the policy-making process-open themselves up to charges of political partisanship. Such accusations have been leveled against The Robert Wood Johnson Foundation at both the state and federal levels.¹⁴

The fourth approach: Get the word out.¹⁵

The Foundation uses communications as a tool to further its strategic interests. It has employed its resources to build public awareness of the astonishing numbers of the uninsured, the oft-tragic consequences of being uninsured, and potential solutions to the problem.

For example, the Foundation supported health coverage by National Public Radio and community radio stations for many years, funded PBS television specials such as How Good Is Our Health Care?, and, in keeping with its philosophy that grantees should do the talking, has arranged for training on how to deal with the media.¹⁶ Linking research and communications, the Foundation organized a series of workshops for print journalists in cities where the Foundation-funded program Health Tracking was conducting surveys.¹⁷

To focus attention on the problem of the uninsured, the Foundation organized, in 1999, a conference of over 400 journalists, policy makers and analysts, and representatives of health-sector organizations. Known as the "strange bedfellows" conference because of the diversity of its participants, it was organized by Families USA and the Health Insurance Association of America.¹⁸Although these two organizations agree on very little, they were able to agree on a plan to cover the uninsured.

Taking a more direct tack, in 2000 the Foundation awarded a large grant to a Washington, D.C.-based public relations firm for radio and television ads to let people know that their children might be eligible for Medicaid or state health insurance. It is part of a larger program, called Covering Kids, to enroll children in Medicaid or state health insurance programs.

The fifth approach: Test innovative ideas and programs.

Such testing is traditionally done through demonstration programs-large applied research projects where different approaches to a problem are tried in different parts of the country. The hope is that successful approaches will be picked up by the government. The Foundation's very first national demonstration program was designed to improve access to emergency care. Taking place in the 1970s just as interest was on the rise-the television series Emergency! was a big hit at the time-the program demonstrated that the 911 emergency telephone service and regional emergency medical services could work. It was later absorbed by the federal government.¹⁹

A large number of demonstration programs have focused on children, many of them designed to improve the access of children to health care services or insurance.²⁰These include programs to establish regional hospital networks for women with high-risk pregnancies,²¹ to provide home nursing for poor pregnant women,²²to establish school-based health clinics,²³ and to provide health insurance to children through their schools.²⁴ Other demonstrations to improve access to care have targeted AIDS²⁵ and tuberculosis,²⁶ homeless people,²⁷ and uninsured people.²⁸ In some cases, the federal government adopted the Foundation's approach and expanded it nationwide. This happened, for example, in the case of community-based programs for the prevention of AIDS and health care services for homeless people.

As the federal government has reduced its role in funding social programs, the Foundation's approach has evolved. In some cases, it now funds large national programs that, as Sharon Begley and Ruby Hearn observed in their chapter in the 2001 Anthology, engage the community and are large enough to have an impact on their own-irrespective of whether a program offers a replicable model.²⁹ The Urban Health Initiative, for example, attempts to improve children's health in entire cities, not just blocks or areas. Faith in Action, The Robert Wood Johnson Foundation's single largest program, provides funds that enable volunteers to help needy people in their communities. While not developed principally to increase access to medical care, the program often does so by funding volunteers to drive chronically ill senior citizens to medical appointments.

The Foundation's efforts to improve access to care illustrate the strengths and limitations of philanthropy in bringing about social change. Over the years, its fellowship programs have trained a cadre of leaders, its research has illuminated the field, its communications have kept the issue alive, and its demonstration programs have provided replicable models. Its efforts to affect policy have sometimes floundered in the messiness of partisan politics; it has not found a wholly satisfactory way to test new ideas now that government is less likely to pick up successful models, and it has been more comfortable with physicians and academics than it has been with activists and community-based organizers.

While some have questioned whether The Robert Wood Johnson Foundation should continue placing such a high priority on the exceedingly difficult problem of access to care, the Foundation's commitment is likely to continue. A retreat by the Foundation, whose efforts have been so visible, would send an unfortunate signal to the field. More important, lack of access to care remains a fundamental problem for our society. A large foundation whose very mission is improving health and health care has an obligation to play a leadership role in addressing this critical issue. And the willingness of the nation to tolerate great numbers of uninsured Americans might change. When this happens, the many years of effort will begin to be rewarded.

Although foundations might not have the power to change the larger forces that move America, the Anthology series shows that by targeting specific areas and making a commitment to them over many years, they can shape the direction of change once it begins happening. The challenge for the future is to develop a strategic vision where philanthropic resources can be brought to bear to increase Americans' access to health care at a time when market forces, rather than social values, predominate; when incentives to avoid serving chronically ill, isolated, and vulnerable people are inherent, and when an economic downturn threatens to increase the number of people without health insurance.

San Francisco Princeton, New Jersey August 2001

Stephen L. Isaacs James R. Knickman Editors