Sound Partners for Community Health

Given the importance of the federal government to The Robert Wood Johnson Foundation’s mission of improving the health and health care of all Americans, it is natural for the Foundation to try to make sure that those who shape health policy do so on the basis of the most current and accurate information. Currently, the Foundation has 219 active grants, totaling $257 million, designed to improve policy-relevant information and to enrich the dialogue that is a key part of the policymaking process. These include support for the journal Health Affairs, for studies coordinated by the Institute of Medicine, for a health policy fellowship program, and for a new program that synthesizes research findings into short policy-relevant reports.

In this chapter Richard S. Frank, the former editor of National Journal and now an adjunct professor of journalism at Boston University’s Washington Journalism Center, discusses the National Health Policy Forum, which the Foundation has supported since 1973. The Forum offers a seminar series on emerging health policy issues for elected officials, members of the executive branch, administrative agency officials, and their staffs.

Striving to be politically neutral, the Forum provides high-quality nonpartisan information and analysis that allow different viewpoints to be heard. (Its approach is similar to that of The Robert Wood Johnson Foundation, which is committed to improving health care and health status, but typically avoids taking positions on partisan issues and specific health policy solutions.) Frank assesses whether being a neutral convener is sufficient in an era of great partisanship.

The Foundation has funded similar health policy forums in a number of states. These state-based forums are advancing a growing field devoted to translating research into practice and synthesizing complicated and sometimes contradictory research findings into formats useful to policymakers.

In many ways, the room, in a Washington hotel a few blocks from the Capitol, resembles a large university lecture hall, filled with students ready to absorb some scholarly information and insight. But many of the 150 people gathered here are not in fact students but are senior aides and advisers to some of the most influential and powerful health policymakers in the federal government. Roughly half of them work on Capitol Hill or in the executive branch, in approximately equal numbers.

They are attending a National Health Policy Forum session on Medicare’s role in paying for the care of the chronically ill. That may not be as politically potent a subject as, for example, how the government should help older Americans pay for the soaring costs of prescription medicine. But it is an issue that policymakers—and particularly their principal aides and advisers—will almost certainly have to understand and deal with when they finally come to grips with the critically important issue of how to keep Medicare financially healthy as the population ages.

Many of the attendees obviously know one another, and as they munch on the buffet lunch offered before the formal session, they exchange personal and professional notes. Others peer at name tags and introduce themselves. A few pull others aside to recommend a new research report or project.
Those present at the early-spring session hear two experts from outside the government and three federal health specialists devote two hours during the middle of a busy day to discussing the problems associated with the increasing percentage of Medicare beneficiaries who have chronic medical conditions. It is the kind of topic and the kind of setting that has identified the National Health Policy Forum since its inception three decades ago. The Forum today remains what it set out to be in 1971: a resource for informal and private exchange of information and ideas about health policy among congressional and executive agency staff members. That’s particularly important, its leaders say, at a time when official Washington’s interest in health policy issues has burgeoned while the expertise of the congressional and executive branch staffs has diminished, in large measure because of increasingly high turnover rates on Capitol Hill.

Stuart Altman, now a professor of national health policy at Brandeis University, was there at the beginning. As a deputy assistant secretary at the old Department of Health, Education and Welfare, he was one of fewer than two dozen health policy specialists working on Capitol Hill and in the executive branch who gathered for dinner one evening in 1971 to launch a series of informal seminars on important issues in their subject area. These seminars soon developed into the National Health Policy Forum. Altman says that the Forum, or something very much like it, continues to be necessary as a way of dealing with the explosive growth of the health policy debate in Washington. In fact, he says, the increasingly partisan tone of the debate may mean that “a neutral voice is needed more than ever.”

The Forum has tried to position itself as a neutral voice from the day it began. Its guiding principle—never to advocate a particular policy and never to take a stand on specific legislation—is intact. But the Forum today confronts some notable paradoxes. The rapid expansion of federal health policy over the years, which should surely be expected to enhance the role of a program dedicated to informing health policymakers, has kept senior congressional health policy aides so busy that they have less time than ever to attend Forum seminars or to read Forum materials. Similarly, in an era of often bitter divisiveness, both ideological and partisan, on most health policy issues, the Forum’s neutrality may not meet the needs of those who are seeking solutions rather than options.

So should the Forum seek to carve out a new role for itself by becoming more of a player—though never a partisan one—by actively developing and perhaps even brokering solutions? Those who lead and advise the Forum respond that adopting such a role would be a serious mistake.

The Forum’s Web site proudly proclaims that since it began, it has conducted more than eight hundred workshops, technical briefings, and site visits. It has also produced more than eight hundred background papers and what it calls “Issue Briefs,” the not-so-brief summaries of the issues that are the Forum’s trademark. Its annual budget had grown to $3.1 million in 2002, of which 90 percent came from foundations, with The Robert Wood Johnson Foundation (27 percent), the David and Lucile Packard Foundation (23 percent), and the W. K. Kellogg Foundation (19 percent) accounting for the largest shares of support. The Robert Wood Johnson Foundation, in fact, has been sufficiently pleased by the Forum’s accomplishments that it has awarded grants to half a dozen state programs that are similar in approaches and goals to those of the Forum (see box).

After three decades, the Forum is clearly a survivor. But can it continue to be effective, given its determination to stand apart from what it has described as “the highly charged politics of Capitol Hill”?¹ In a harshly divided national capital, is impartiality enough? The Forum’s answer: for the good of the public policy system, it had better be.

Informed neutrality was the Forum’s goal from its inception. In 1971, Medicare and Medicaid were only six years old, but Congress was already beginning to fine-tune these two huge government programs. Health care, though not the ascendant political issue it has since become, was already looming as a major congressional subject. To Altman and his colleagues in the executive and legislative branches, it was imperative that they—and through them, their principals in the Nixon administration and in Congress—
have the information they needed to make sound policy judgments.

With a Republican in the White House and Democrats in control of Congress, the health policy aides found themselves working in a climate of political distrust. And with the executive agencies as the primary source of information on health care, many congressional Democrats were starting to express doubts about the objectivity of that information. One solution that seemed to appeal to some of these aides was already being tried out in the field of education policy: Why not bring congressional and executive health policy staffs together to exchange information and views and—perhaps as important—to try to break down the walls, real or imaginary, that appeared to divide them?

A program called the Educational Staff Seminar had been functioning for several years, holding meetings in Washington and conducting occasional out-of-town site visits. It seemed a likely model for the health policy specialists to adopt and adapt. (In fact, the organization that ultimately became the National Health Policy Forum was known in its early years as the Health Staff Seminar.) After all, Washington was spending much more on health than on education, Judith Miller Jones, the Forum’s director, recalled in a recent interview. Jones, at the time a legislative liaison for the Department of Health, Education and Welfare (now the Department of Health and Human Services), was one of the Educational Staff Seminar participants. She was asked to help Altman and the other health policy specialists write a planning grant application to the Carnegie Corporation of New York to get the program started. It was officially launched under the auspices of The George Washington University, which has been its sponsor ever since.

The start-up grant from Carnegie allowed the new group to hire a small staff, and Jones became its first—and only—director. Her experience at the time was limited to a year at the Department of Health, Education and Welfare and two years as an aide to Senator Winston Prouty, a Vermont Republican, for whom she specialized in education and, as she recalled, “a little bit” of health policy. In 1973, The Robert Wood Johnson Foundation provided a small sum for a study to determine whether it should help the new group financially. It decided to do so “and took us under its wing,” Jones said. Initially, the Foundation awarded the Forum a three-year grant of $498,000. It subsequently became the Forum’s major supporter and has so far provided it with slightly more than $10 million in grants.

From the beginning the Forum’s mission has been to offer “a unique, off-the-record setting for interaction and exchange of ideas, removed from the highly charged politics of Capitol Hill.” The group’s organizers, Jones recalled, made an early decision not to seek or accept federal money for the program, as had the Educational Staff Seminar, and therefore not to become beholden financially to the executive branch.
But while the Forum has not sought federal financial help, the inclusion of executive branch aides has always been an important part of the Forum’s philosophy. In fact, about 40 percent of the members of the Forum’s policy-setting Steering Committee are from executive branch agencies. An equal number are legislative aides, with staff members of congressional support agencies filling the rest of the committee’s slots.

The heart of the Forum’s program has always been its seminars—almost always off the record—on important but sometimes arcane issues of health care policy. The Forum’s intention from the start was to bring senior congressional and executive staffs together to discuss these issues while carefully sidestepping any temptation to offer political advice. Outside policy experts and real-world practitioners are regularly invited to present their views to the legislative and administrative staffs and to join in discussing the subject.

“When this program got started, we were all terribly naïve,” Jones said. Medicare and Medicaid were both still in their infancy, she pointed out, and policymakers “didn’t really understand the links between money and health care,” such as how doctors and hospitals are paid, the role of insurers, and how the two vast new federal programs were driving costs. “We didn’t yet grasp just how health care delivery systems were affected by these huge dollar flows.”

The Forum has undoubtedly lost its naïveté since 1971. It has also lost part of its audience during the past three decades—a loss that poses questions about the program’s continued vitality.

Historically, the staff members of the congressional committees and subcommittees responsible for health policy made up the Forum’s core audience.² But as the health policy workload and complexity have increased, these staff members have found it increasingly difficult to keep on top of all the issues. At the same time, for many of the aides on the personal staffs of committee members, health policy is only one of several subjects in their work portfolio, and these aides necessarily lack the specialized expertise of committee staff members. Moreover, staff turnover is a problem; the Forum has noted that many congressional aides “use their Hill experience as a stepping stone to a remunerative lobbying or trade association position.”³

Staff turnover, whatever the cause, has required the Forum to make some adjustments. For example, Jones said, when the Democrats took control of the Senate in 2001, the health staff of the Senate Finance
Committee asked the Forum to brief it on the Health Care Financing Administration’s governance role on Medicare and Medicaid. The Forum responded with four briefings and a site visit. In the fall of 2002, Jones said, the committee staff members asked for help in running briefings on the fundamentals of the Medicare and Medicaid programs for new health policy aides, perhaps on an annual basis. They asked for the briefings on such a basic subject, Jones said, “because they recognized that high turnover was hurting their productivity.”

So, for example, on January 23 and 24, 2003, the Forum held an invitation-only seminar titled “Understanding Medicare and Medicaid: Fundamentals and Issues for the New Congress,” with a voluminous “electronic briefing book” on the subject—links to various documents, charts, and PowerPoint presentations. The session, which the Forum said on its Web site was “requested by congressional staff to provide an overview of the Medicare, Medicaid, and State Children’s Health Insurance programs,” was clearly a response to the turnover problem. But “basic training” sessions like that may risk diminishing the Forum’s relevance as the source of leading-edge policy information.

The growth of staff positions in congressional support agencies— the General Accounting Office, the Congressional Budget Office, and the Library of Congress’s Congressional Research Service—has helped to compensate for the decline in the size of committee staffs. Many of the support agency aides with expertise in health policy expect to stay in their positions “indefinitely,” the Forum has pointed out. Meanwhile, participation by executive agency staffs has continued, and, as a consequence, “the Forum’s audience has become larger and more diverse than in the days when Hill staff dominated Forum activities.”⁴

Whether that diversity serves the Forum’s goals has been the subject of some debate. “We now serve the congressional [support] agencies as our lead audience,” Jones said during the interview. “They come to our meetings, and then, in turn, they brief the newer, less experienced congressional committee staffs. That’s a big change. It’s like training the trainers.”

A particular concern of some observers of the Forum’s work is that the most influential people on Capitol Hill may be staying away from the off-the-record policy seminars. “The Forum will maximize its influence to the extent it is attended by individuals (or its materials are read by individuals) who are likely to influence policy,” concluded a 1997 assessment of the Forum conducted for The Robert Wood Johnson Foundation by New Directions for Policy, a Washington-based policy research, analysis, and strategic planning firm. Linda Fishman, the health policy director of the Republican staff of the Senate Finance Committee and a member of the Forum’s Steering Committee, agreed that for senior congressional aides “it’s very hard to break away” to attend the often lengthy seminars. Linda T. Bilheimer, who, as a Congressional Budget Office official, served on the Forum’s Steering Committee until she moved to The Robert Wood Johnson Foundation at the end of 1999, assigns the blame to high congressional turnover. “The senior, experienced staff are stretched unbelievably thin,” she said. “So for them, getting away to meetings is extremely hard.” For the inexperienced staff, on the other hand, “the level of the material may be too hard for them because the Forum pitches to quite a sophisticated audience.”

Bilheimer, now the Foundation’s senior program officer monitoring the Forum, said that the Forum was getting requests to provide “more basic education on the Hill,” not necessarily at the regular seminars but instead at separate sessions for various committee staffs. She said that doing this would preserve the high level of sophistication at the seminars while offering basic education on health care policy for the less experienced. Senior Hill aides, Bilheimer suggested, would come to special, restricted- attendance meetings if they were held in addition to the larger meetings. Whether justified or not, she said, the senior staff members believe they get more out of “meeting with a small group of their peers than being in a larger group.”

The 1997 evaluation report pointed to another irony: that the Issue Briefs distributed before every seminar were such good summaries of the subject that their very excellence “may detract from attendance at the meetings.” Bilheimer is skeptical. She acknowledged that while she was at the Congressional Budget Office, where she was the deputy assistant director for health, she “always appreciated the quality of the Issue Briefs, because it meant that if I couldn’t go to a meeting, I had the documents at hand.” “But,” she added, “I did try to go to meetings if I could because the Forum has done a good job of bringing in speakers who aren’t the usual suspects. And I often found that I could hear viewpoints expressed at the meetings that greatly enriched the materials that were available in the Issue Briefs.”

Jones agreed that some Capitol Hill health policy specialists may be too busy to attend the seminars. She noted that some of them call the Forum office to find out what happened at a meeting they had missed. On the other hand, she said, others want to come to a meeting “to see how other people are facing the issue. They want to schmooze.” Jones also pointed out that the Issue Briefs, along with the Forum’s lengthier background papers, are available at the organization’s Web site.

Most health policy subjects worth considering are certain to be controversial. For a program that’s determined to preserve its neutrality, the Forum’s challenge is to avoid controversy while concentrating on deeply contentious topics. It must also strive to be timely without slavishly adhering to anyone’s legislative or administrative agenda.

The narrow line the Forum must walk requires that it choose its topics carefully and then develop and present information that’s useful but nonprescriptive. The Forum’s Steering Committee has the dominant role in deciding what to look at; the Forum’s staff is responsible for the way the topic is presented.
The Forum’s staff periodically presents the Steering Committee with a list of proposed activities—seminars and other meetings in Washington and site visits to other locales—for the next twelve months. The committee, which has approximately forty members who work for members of Congress, congressional committees and support organizations, and executive agencies, then accepts, rejects, or modifies items on the list. So, for example, a list prepared in September 2002 included thirty-three proposed activities. This list, which gives a sense of the range of issues the Forum typically has on its calendar, included these activities:

Sometimes, according to Jones, “the committee will say, ‘This is a terribly important issue, but put it later because other things have come up that we have to get to sooner.’ Other things, they tell us, ‘Move it up on the agenda.’”

At one time, Jones said, the Forum had an external advisory board to guide it in its selection of topics. “But the Steering Committee members said they didn’t want any outsiders ‘telling us what we need to look at. We know what we need to know, and we’re not going to have them veto what we say.’”

Steering Committee member Fishman said that Jones “listens to health staff” in choosing topics. “We identify what are the hot topics. We’ll say, ‘Gee, that needs to be pushed up, we need to know that sooner, that one is less important, wait on that one.’ We identify what’s important, the hot topics, the things we need information on right away” because legislation on the subject is before Congress.

Bilheimer views the process as “sort of a two-way street. The Forum staff generates ideas for topics,” and the Steering Committee responds. When she was a Steering Committee member, she recalled recently, “we would go to meetings, and a very lengthy list of potential topics would be produced” by the Forum staff. “And the committee would say, ‘We think this is the greatest thing since sliced bread,’ or ‘We don’t quite understand where you’re going with this one,’ and would cull down to the ones we thought were really important. We would also raise ideas for topics that we thought were important.” Moreover, she said, if the key people on a committee staff said that they saw the need to study a particular topic, “the Forum staff would jump” and add that topic to the agenda.

In deciding which issues to put on its calendar, the Forum staff is aware of the interests and goals of its primary financing sources, The Robert Wood Johnson Foundation, the David and Lucile Packard Foundation, and the W. K. Kellogg Foundation. But Jones, Bilheimer, and program officers for the other foundations agree that they don’t dictate the subject of specific Forum topics.

Packard’s primary interest in the health policy arena involves issues of children’s health. It encourages the Forum to come up with topics in that area, said Eugene Lewit, the foundation’s senior program manager for the Forum. But he added that Packard avoids recommending specific subjects to the Forum.

Barbara Sabol, program director for the Forum at Kellogg, explained in an interview that the Forum each year submits a proposal that states what it intends to focus on that year. Kellogg comments on the list, she said, and also keeps the Forum informed of what the foundation is up to. One of Kellogg’s objectives is “to get feedback on national policies,” Sabol said. And though health care is not Kellogg’s major area of interest, “there are a lot of cross-cutting issues involved, such as education, in which child health care plays an important part. So what the Forum does relates to many of our issues.”

From the very beginning, Jones said, Robert Wood Johnson Foundation officials insisted that the Forum avoid any appearance that they were driving its agenda. The Foundation staff told her, she recalled, “We’re not going to control what you do, because it’s tremendously important that people see this as a safe haven, where they can learn from each other.” She added that the Foundation’s grant to the Forum “is written in such a way that they know we’re going to cover the waterfront. We also know what their priority areas are.”

For the Foundation, the Forum meets a very particular need, Bilheimer said, and while the Foundation has broader health policy interests than the Forum has, it deals with those interests in other ways. From time to time, she explained, the Foundation will tell the Forum staff that “we think it would be helpful” for the Forum to have a meeting on a specific topic. And sometimes Bilheimer will tell the Forum staff that other Foundation grantees have been working in a subject area “that it might be really interesting to have a Forum session on.” If the Forum staff chooses not to add the topic to its agenda, that’s fine with the Foundation, she said, adding that even if the staff likes the subject, the Steering Committee has to agree.

The Forum has, in fact, responded negatively on one subject dear to the Foundation: behavioral issues such as alcohol and drug abuse and smoking. Over the years, the Foundation has encouraged the Forum to conduct meetings and prepare Issue Briefs on the topic, and from time to time the Forum has done that, according to Jones. But the Forum, she added, has also told the Foundation that “such issues are not high- priority to most of the audience and tend to attract the already convinced. And there are limits to what people think government can and should do, especially at the federal level, while foundations have a much broader array of options to support.”

Nevertheless, the Forum depends on the money it gets from foundations, and if a major contributor is interested in a particular broad subject, the Forum is going to be especially cautious about ignoring it. The Forum’s lone complaint about its relationship with The Robert Wood Johnson Foundation, Jones said, “is one we have never solved. They expect us to read their minds and know everything that they’re doing. And if we don’t mention it, we get blamed.” This has been a problem for thirty years, she said. “Does the Foundation want to control things? No. Do they want to maximize impact by having everybody on the same wavelength? Sure. As much as possible.”

Foundations other than Robert Wood Johnson, Packard, and Kellogg—the Forum also receives grants from the California HealthCare Foundation, the Flinn Foundation, the John A. Hartford Foundation, and the John D. and Catherine T. MacArthur Foundation—make fewer demands on the Forum’s agenda.

The Forum also receives money from corporations with strong business interests in health policy. It tries to avoid any hint of improper influence, Jones said, by limiting total corporate contributions to about 1 percent of the Forum’s budget, by declining grants for specific purposes, and by mingling the corporate gifts with its other revenue. The Forum has received corporate support from pharmaceutical companies such as GlaxoSmithKline, Johnson & Johnson, Merck, and Pfizer; health insurers such as Blue Cross Blue Shield, Kaiser Permanente, and UnitedHealth Group; and other health-related companies.

Accepting corporate grants “came about by accident,” Jones said, when the Forum was studying health insurance and she went to the Prudential Insurance Company of America for some information. Prudential offered her what she described as “a token amount of money.” She went to her Steering Committee, which decided, in her words, that if insurance companies were part of the problem, “they ought to be part of the solution.”

Only once, Jones said, has a corporation “tried to manipulate us.” That was a drug company, which she declined to identify and which no longer exists, whose money was returned. She added that a foundation tried the same thing and was dealt with in the same way.

After getting its marching orders from the Steering Committee, the Forum staff of about twenty organizes the meetings and site visits and puts together, sometimes with the help of outside writers, the multipage Issue Briefs, the even longer background papers, and the reports on Forum site visits. Whether the staff writes the papers depends on its expertise on the subject, Jones said. If necessary, she will employ freelance writers, including two former staff members who write regularly for the Forum. “We also have a few stringers we use,” she said. “And we pay them well. But you can’t continue a program with just stringers.” Moreover, she said, some former contributors turned in work that the Forum wouldn’t publish.
“It’s a problem we’ll never be able to fix,” Jones said. One reason for the difficulty, she pointed out, is that some of the outside writers “aren’t used to writing in a nonpartisan, objective way” and that some of them “are advocates at heart.”

How successful are the Forum’s writers—in-house or outside—in avoiding the extremes of cold-blooded neutrality and warm-blooded advocacy? A review of some recent Issue Briefs suggests that they have struck the appropriate balance between identifying and analyzing a problem and recommending a course of action. Two recent Issue Briefs might also serve as examples of how to handle political hot potatoes without any risk of burning hands or mouth.

In June 2002, the Forum published an Issue Brief titled Average Wholesale Price for Prescription Drugs: Is There a More Appropriate Pricing Mechanism? The brief carefully sidesteps endorsing any particular solution to the important and politically sensitive problem of prescription drug pricing while making it clear that the average wholesale price mechanism has major defects. Its concluding paragraph is worth quoting in full as an example of the Forum’s approach:

The AWP [average wholesale price], a pricing mechanism that by most accounts is seriously flawed and not widely understood, plays a pivotal role in the overall prescription drug pricing and reimbursement systems. It has become a critical benchmark for key stakeholders, despite its inability to accurately reflect the “true cost” of drugs. Yet, as we have seen, the true cost of a given drug depends on the various discounts, rebates, and reimbursement formulas available to a particular purchaser—both public and private. Other alternatives to the AWP may suffer from similar flaws, namely, being subject to manipulation and not closely aligned with real market transaction prices. The creation of an appropriate payment mechanism for prescription drugs, therefore, will need to involve a careful balance between protecting the proprietary nature of drug pricing information and ensuring the accuracy of, and accountability for, the information on which such a payment mechanism is based.⁵

Three months later another Issue Brief, titled Medigap: Prevalence, Premiums, and Opportunities for Reform, comes even closer to the line between descriptive and prescriptive without crossing it. It ends this way:

Budget constraints mean that the tension between providing catastrophic coverage to the sickest beneficiaries and first-dollar coverage for those who are risk-averse will likely worsen with time. In light of changes to retiree health insurance plans and M + C [Medicare + Choice] plans, the time seems ripe to reconsider whether the Medigap market is fulfilling policymakers’ goals and expectations.⁶

As for its goal of timeliness, the Forum was reacting to Congress’s scramble to meet a recently revealed need when it published an Issue Brief in June 2002 with the title Will the Nation Be Ready for the Next Bioterrorism Attack? Mending Gaps in the Public Health Infrastructure. The Issue Brief’s baleful conclusion: “Fortifying the public health infrastructure will clearly be a long-term endeavor. . . . The potential for a real reform of public health preparedness capabilities will depend on the sustained involvement and commitment of policymakers at all levels of government. Close scrutiny must be paid to determine what is working, what is not, and what additional measures need to be pursued.”⁷

In asking The Robert Wood Johnson Foundation in 1999 to renew its grant, the Forum had this to say about its policy mission: “While the Forum never takes positions on political proposals under debate, we
believe that our activities often make the debates more informed and knowledge-based than they otherwise would be.”⁸

Not everyone agrees with that position, however. In the 1997 evaluation of the Forum, several congressional aides suggested to the evaluators that the seminars could be more useful if they discussed legislative solutions more directly. While that suggestion falls short of a demand to propose solutions, it is clearly a call for the program to present an array of possible solutions even if it doesn’t single one out for recommendation.

The Steering Committee’s Fishman, for one, takes issue with the suggestion. The Forum, she said, “tries to be straight-shooting presenters of information without having a point of view.” It needs to pay attention to the hot legislative topics, she added, “but not in a partisan way.”

Jones has equally strong views on the subject. “Some people wanted us to recommend solutions,” she said. “But the Steering Committee said no, because the moment you do that you alienate one side or the other.” Offering solutions, she added, is “what lobbyists are paid to do.” After the Republicans captured control of the House in the 1994 elections, “we were the only program that was still seen as neutral,” Jones said. “Every other program was seen as tainted by one side or the other.” Admittedly, Jones said, some senior people call the Forum from time to time to ask what the staff thinks about a particular legislative proposal. “We’ll respond,” she said. “But we have to be very careful that we don’t look like lobbyists.”
Politics and political wrangling are inescapable, of course, in discussing almost any kind of health care legislation. The Forum has tried to cope with the problem in a variety of ways.

In the fall of 1998, the Forum wrote in its annual progress report to The Robert Wood Johnson Foundation that during the previous twelve months “it became clear that the divisiveness in Washington and changes in the policy apparatus and legislative process demand new ways of doing business.”⁹ That was not the last time it would sound the alarm about Washington’s growing political rancor.

In its report to the Foundation in 2000, the Forum observed that “the increased practice of ‘coalition politics’ by powerful Washington lobbyists, whereby interest groups continually realign to apply political pressure on members of Congress, often means that policy concerns are driven underground by political machinations.” The report goes on to discuss the Forum’s role in the policy debate: “Despite the poisonous atmosphere that such tactics often create, it is ironic that their prevalence in the current era actually underscores the need for a nonpartisan, objective forum to examine the merits of legislative proposals. The National Health Policy Forum, of course, has played this role for almost three decades.”¹⁰
The same report also offers a pair of pointed examples of the Forum’s role and the influence of politics on the way the Forum does its work.

In both cases, the Forum acted as a facilitator—trying to help others to achieve their goals.
One of them involved the politically sensitive question of whether Medicare should move away from administered pricing toward more competitive pricing in buying medical services, particularly those provided by managed care plans. In the fall of 1999, with Congress deadlocked over whether to conduct demonstration projects on the subject, key congressional and executive branch aides asked the Forum to organize a small, off-the-record session “to promote dialogue among the key players” on the issue, according to the Forum’s annual report. The meeting, hosted by senior Republicans on the staff of the Senate Finance Committee, was attended by other senior congressional aides and by high-
ranking administration officials. The result, the Forum report says, was that key congressional staff, previously reluctant to become involved in the subject, changed their minds and became engaged. Ultimately, however, Congress decided against taking any action on the issue.¹¹

The Forum, in the same report, offered another illustration of its role as facilitator. As part of its effort to examine the effects on hospital-based health systems of the 1997 Balanced Budget Act and legislation that followed it, the Forum conducted site visits in March and April 2000 to Richmond, Virginia, Detroit, and Seattle, followed by a two-day conference in Annapolis, Maryland, at the end of April. Holding so many out-of-Washington sessions in such a short time was a serious drain on the Forum’s time and limited budget. So why did it undertake this resource-straining project? According to the Forum’s progress report, congressional health aides wanted to be armed with sufficient information to beat back lobbyists’ attempts to carve out federal health funds for their clients and pressed the Forum to accelerate its efforts to come up with that information. As the Forum observed in its report, “scheduling meetings has become an increasingly political matter.”¹²

Capitol Hill certainly has no shortage of information on health policy issues. Lobbyists, think tanks, and congressional research offices provide an almost endless flood of information on the issues, large and small, that Congress has to contend with. But information provided by a group without a stake in the outcome is uncommon, the Forum’s defenders say, and sometimes priceless. Even more important, they add, is its closely related mission of bringing congressional and executive branch health policy staffs together, out of the political spotlight, to exchange views and get to know their policy counterparts. In an era of partisan and ideological division, that’s the role the Forum is determined to play: to be a facilitator, not a broker of agreements.

“The way things are today, there’s no role” for the Forum in trying to offer specific solutions or even a range of possible solutions, said Charles (Chip) Kahn III, the president of the Federation of American Hospitals and former staff director of the House Ways and Means Health Subcommittee. “I don’t think that would be sustainable,” given “the sharp partisan divide” in Congress today. The Forum’s proper role, he said in an interview, should combine providing information and bringing opposing sides together.
The Kellogg Foundation’s Barbara Sabol agrees: “I think it’s imperative that there be places where one can have discussions about the issues that are not adversarial. They don’t necessarily have to agree with each other, but the facts can be examined in a nonpartisan way.”

That is no easy assignment. But Forum officials say they are convinced that it is at least as pertinent today as it was when the organization was born three decades ago. Jones put it succinctly in a recent interview. Some people, she said, want to know only their side of an issue, while others want to understand the issue. “They’re the ones who ask, ‘How do I sort it out?’ We appeal to the latter.”