Health Affairs

Editor’s Note: GrantWatch Blog invited Roger Hughes, executive director of St. Luke’s Health Initiatives (SLHI), a public foundation in Phoenix, Arizona, to write a post commenting on the new Arizona immigration law, passed 23 April 2010, and its potential effect on health in that state. SLHI does most of its funding in the Phoenix metro area. This funder “is focused on Arizona health policy and strength-based community development,” according to its Web site. Comments to this post are welcome!

GrantWatch Blog has added a few related resources below Roger’s post.

St. Luke’s Health Initiatives (SLHI) funds a number of neighborhood projects where promotoras (community health outreach workers) make house calls. They tell us that some Hispanic families have been refusing to go with them to a community clinic because they are afraid of being deported. When a family member does go for care, it’s often to the emergency room for something that could have been prevented earlier.

In the town of Guadalupe, Arizona, where my wife teaches third grade, some kids have been coming to school sick because their parents are afraid to take them to see a doctor. Two years ago, Joe Arpaio, America’s “toughest sheriff,” conducted a “sweep” of this heavily Hispanic community looking for people who were in the country illegally. He did it, of course, to root out crime and make the streets “safe for law-abiding citizens.”

Today, Arizona’s hard-line stance against illegal immigration is over the top. The new law (SB 1070), signed by Gov. Jan Brewer (R) in April 2010, requires that law enforcement officials or any “agency of this state or a county, city, town, or other political subdivision of this state” make a “reasonable attempt” to determine the immigration status of someone where a “reasonable suspicion” exists that they are an “alien who is unlawfully present in the United States.”

The new law makes a bad situation even worse. Hispanics whose families have been in Arizona for decades tell us that they are preparing to carry documentation proving citizenship in the event that they are pulled over because they look “suspicious.” Children born in Arizona of parents here illegally could conceivably be accused of “transporting aliens” if they had to drive their mother or father to the emergency room at 3 a.m.

It’s insane. There is no other word for it. It is impossible to foster healthy individuals and communities in a climate of fear and intimidation. Community outreach programs, health fairs, local partnerships aimed at healthy eating and active living – all of it can come undone if people are afraid to leave their homes and visit a clinic, hospital, local community center, or church.

The law’s principal crafters are likely to achieve their objective of making Arizona an inhospitable place for people who are in the country illegally. Unfortunately, they run the risk of making Arizona a state where fewer and fewer Americans are likely to want to visit or live.

______________________________

Related resources:

“Arizona Immigration Law Backlash Intensifies: Protests, Boycotts, and Lawsuits Mount Up as State Feels Wrath of Opponents to Its New Policy,” CBS/Associated Press, 30 April 2010

“GOP Holds Ground as Dems Offer Immigration Plan,” Kasie Hunt, Politico.com, 30 April 2010

“Common-sense Principles for Immigration Reform,” Celia Hagert, Center for Public Policy Priorities (Austin, Texas) Policy Page, 29 April 2010.

“From the Talk to the Walk,” Roger Hughes wrote an essay (free access) on mental health and health policymaking, from a foundation executive’s view, in Health Affairs’ Narrative Matters section, May/June 2003. Narrative Matters is funded by the W.K. Kellogg Foundation.

“Hispanics and Arizona’s Immigration Law,” Pew Hispanic Center of the Pew Charitable Trusts, fact sheet, 29 April 2010.

“Immigrants and Health Care: Sources of Vulnerability,” Kathryn Pitkin Derose, Jose J. Escarce, and Nicole Lurie, Health Affairs, September/October 2007.

“Improving Coverage and Access for Immigrant Latino Children: The Los Angeles Healthy Kids Program,” Ian Hill, Lisa Dubay, Genevieve M. Kenney, Embry M. Howell, Brigette Courtot, and Louise Palmer, Health Affairs, March/April 2008. Research for this article was funded by contracts with First 5 LA and the California Endowment.

The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission.

 The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts.

This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care.

The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.

The inclusion of the Community-Based Care Transitions Program in the health reform law is important evidence that foundation-funded work is informing the development and implementation of national policy and has the potential to improve the quality of care for older Americans.

To promote the uptake of proven strategies that improve transitions of care, the Commonwealth Fund and the Hartford Foundation partnered with the Health Research and Education Trust (HRET), a subsidiary of the American Hospital Association, to develop the “Health Care Leader Action Guide to Reduce Avoidable Readmissions.” This new resource (which can be downloaded at no charge) outlines approaches to improving quality of care—such as the Care Transitions Intervention. It also addresses issues that lead to costly rehospitalizations, such as lack of appropriate follow-up care, or confusion over medications, which can lead to serious errors and harm.

 For more information on the Care Transitions Program, please visit http://www.caretransitions.org, including its “Influencing Policy” section.

For more information on the Health Care Leader Action Guide to Reduce Avoidable Readmissions, please visit http://www.hret.org/hret/programs/readmissions.html.

Two-thirds of registered voters in California (age forty and older) say that they are worried about the future costs of long-term care for themselves or a family member, according to survey results released 21 April 2010. The “concern crosses party affiliation,” with majorities of Democrats, Republicans, and independents being worried about affordability, the full survey report said. 

This survey from the SCAN Foundation and the Center for Health Policy Research of the University of California at Los Angeles (UCLA) also found that only 15 percent of respondents report that they have long-term care insurance. Also troubling is the fact that only 30 percent of respondents know that Medicare does not cover long-term nursing home care. Just 20 percent of all respondents are “aware that Medicare does not cover in-home [long-term] care.” Respondents with the lowest incomes (under $30,000 a year) “are among the least likely to know that Medicare covers neither nursing home nor in-home long-term care,” the researchers said.

Not surprisingly, 95 percent of respondents say that that it is important to have affordable care alternatives available so that “older people can get help in their homes and communities” and avoid going into nursing homes.

Eighty-seven percent of the voters polled say that it is important for California’s candidates for governor this year to talk about the importance of long-term care in their campaigns, the press release mentioned above noted.

 The release also contains a box that teases out Latino respondents’ views on several of the survey questions.

Lake Research Partners and American Viewpoint conducted the survey of more than 1,200 registered voters in March 2010. Polling was done in English and Spanish.

Related resources:

Family Caregiver Alliance (FCA), http://www.caregiver.org/caregiver/jsp/home.jsp. The FCA acknowledges numerous funders listed here.

Health Affairs, January 2010 issue, which has the theme “Advancing Long-Term Services and Supports.” The SCAN Foundation funded this issue of the journal.

In honor of Earth Day 2010, I thought I would mention a few foundations that have funded environmental health efforts.

While I was at the Grantmakers In Health (GIH) annual meeting in Orlando, Florida, in March 2010, I attended a session titled “Environmental Justice at a Crossroads: From Protest to Sustainability.” Unfortunately, as it was one of the last sessions at this well-attended conference, people had begun to leave, and there was only a small audience to hear about the important topic of environmental health.

Center for Community Action and Environmental Justice

David Fukuzawa, of the Kresge Foundation, was the session’s moderator. The first speaker was Penny Newman, of the Center for Community Action and Environmental Justice (CCAEJ). Newman talked about the origins of the nonprofit, grassroots center and its work in Riverside County, California, which she described as a large county with high levels of poverty. Newman’s biography in the GIH program points out that she “has gained wide recognition” for the center’s “model of engaging those most directly affected by an issue in policy advocacy through community organizing and leadership development.” She and others in the rural community of Glen Avon, California, first became concerned about toxic chemicals being discharged from open ponds at the Stringfellow Acid Pits into their community. The CCAEJ’s Web site describes “the Acid Pits” as “California’s top [federal] Superfund priority site and one of the most notorious toxic dumps in the nation.”

Although Newman and other residents were called “hysterical housewives,” they started organizing because residents’ exposure to chemicals from the site was “a health issue,” she told us at the GIH session. Read about the center’s many accomplishments here. She gave the attendees some advice: If you are working for environmental justice, it’s better to avoid trying to shut down a facility, because that would cause a loss of jobs. Instead, try to improve the facility!

The James Irvine Foundation, Kresge Foundation, California Wellness Foundation, William and Flora Hewlett Foundation, and the California Endowment are among the CCAEJ’s funders, Newman told Health Affairs’ GrantWatch Blog. The center now has a staff of eleven.

West Harlem Environmental Action, Inc.

The other speaker at the session was Peggy Shepard, the executive director and cofounder of West Harlem Environmental Action (called WE ACT for Environmental Justice), a grantee of the New York Community Trust. The Harlem section of New York City is a high-density area, with many African Americans and Latinos, she reminded us. According to WE ACT’s Web site, the group is “dedicated to building community power to fight environmental racism and improve environmental health, protection and policy in communities of color.” The group, which began as a group of volunteers but now has a paid staff, first focused its efforts on a sewage treatment plant, Shepard told attendees. WE ACT filed a lawsuit against the city in 1988, which got the city to fix the North River Sewage Treatment Plant and led to a $1.1 million settlement, which was to be used to establish a “fund to address community concerns related to health, environment and service delivery,” WE ACT’s Web site says. Part of the settlement was used to establish WE ACT as a formal “West Harlem planning and advocacy organization.”

WE ACT was also concerned about abandoned cars being left in the neighborhood, as well as the depots for diesel buses located in the vicinity, Shepard said. Twelve years ago, WE ACT began to work with Columbia University’s public health school to research the effects of diesel fumes as well as pesticides, Shepard said. Len McNally of the New York Community Trust, an attendee at the GIH session, noted that Columbia has been “a real partner” in these efforts.

Shepard commented that the public health impact of climate change is important, and her group wants to work on that problem in the future. Most of the health-related legislation in Congress, she maintained, does not address public health. She also commented that it is hard to get funding for community organizing, as some foundations shy away from supporting that.

A few related resources on environmental health:

Health and Environment Funders Network, commonly known as HEFN.

The Heinz Endowments’ Environment Program. Also, read a press release about the third Women’s Health & the Environment Conference, which was held just yesterday, 21 April 2010.  The conference was sponsored by Teresa Heinz, the endowments, and Magee Women’s Hospital of UPMC. Surgeon General Regina Benjamin and Environmental Protection Agency Administrator Lisa Jackson both spoke, Doug Root, a spokesperson for the endowments, confirmed. He also sent the GrantWatch Blog a summary of their remarks.

Benjamin told attendees that her main responsibility as surgeon general is to focus on wellness and prevention, but she is learning, she said, that living up to that responsibility requires much more of a focus on environmental toxins in air, water and food. “In this position, all Americans are my patients and I need to advise them on environmental threats to their health.”

In . . . Jackson’s remarks, she asserted that women, as the chief purchasers of food and most consumer goods in the home, and in their role as caregivers, make up the one group in our society most empowered to insist on regulations that will protect Americans from environmental hazards. She said that outdated regulatory powers given to the EPA, bad court decisions and too much money influencing the process, have jeopardized Americans’ health. She said that women have the power to insist that good science be the sole definer of environmental health policy.

Read a Pittsburgh Post-Gazette article written in anticipation of the conference. Teresa Heinz, who is the widow of the late Sen. John Heinz (R-PA) and the wife of Sen. John Kerry (D-MA), chairs the Heinz Endowments.

Physicians for Social Responsibility. Also, read this group’s November 2009 report Coal’s Assault on Human Health. The report was funded by the Energy Foundation and the Compton Foundation.

“W.K. Kellogg Foundation Awards $380,000 to Physicians for Social Responsibility,” 1 March 2010 press release about a grant to launch the Safe and Healthy Children Initiative, which “will address pediatric environmental health in migrant and seasonal farmworker children.”

The following items on a spectrum of topics have come across my desk recently, and you may want to check them out. I have listed them, along with the links, under the relevant subject headings.

Health Care for the Elderly

The MacArthur Research Network on an Aging Society “is an interdisciplinary group of scholars who are conducting a broad-based analysis of how to help the [United States] prepare for the challenges and opportunities posed by an aging society,” according to an April 2010 brochure released by the John D. and Catherine T. MacArthur Foundation. Network members include the chair, John Rowe of the Mailman School of Public Health, Columbia University; Dana P. Goldman of RAND; and John Rother of AARP. Please note that health is just one of the network’s interests.

Health Professions

Redesigning Continuing Education in the Health Professions was released by the Institute of Medicine (IOM) in December 2009; the report was funded by the Josiah Macy Jr. Foundation (see the list of the foundation’s funding priorities foundation’s funding priorities on its Web site). Gail L. Warden, now a professor at the University of Michigan’s School of Public Health chaired the IOM panel that prepared this report. According to an executive summary of the report, “the absence of a comprehensive and well-integrated system of continuing education (CE) in the health professions is an important contributing factor to knowledge and performance deficiencies at the individual and system levels” in the United States.

Have you always wanted to apply for one of the Robert Wood Johnson Foundation’s (RWJF’s) programs that award funding to individuals, but didn’t know if you were eligible? The RWJF’s Scholars, Fellows & Leadership Programs Web site was launched in March 2010. This “information clearinghouse” includes profiles of RWJF scholars, fellows, and leaders; application deadlines for sixteen of the foundation’s programs, such as the Investigator Awards in Health Policy Research; alerts about events; and a place to ask questions about the programs.

Related resource:

“Improving the Long-Term Care Workforce Serving Older Adults,” Robyn Stone (American Association of Homes and Services for the Aging) and Mary F. Harahan (independent consultant), Health Affairs, January 2010.

Health Reform

“Summary of New Health Reform Law,” Henry J. Kaiser Family Foundation, 8 April 2010. This “reflects provisions” of the Patient Protection and Affordable Care Act and “changes made by subsequent legislation,” the foundation says. As the Center for Public Policy Priorities (Austin, Texas) said, this is “an excellent 13-page table” on the legislation. Because it is well-organized and succinct, I have found it a useful reference.

 “What Just Happened? Still Processing,” Minna Jung of the RWJF, The Users’ Guide to the Health Reform Galaxy blog, 8 April 2010. You may relate to Jung’s musings here as she started looking through the lengthy new health reform law. This RWJF blog also has a weekly feature called “Health Reformer’s Lexicon,” which examines “key words, terms and phrases in health reform and explores their meaning and orbit.”

Related resource:

“CMS and Health Reform: A Health Affairs Blog Roundtable,” Chris Fleming (the journal’s social media manager), 13 April 2010. This post on the Health Affairs Blog is about a roundtable discussion among former heads of the Centers for Medicare and Medicaid Services (or the Health Care Financing Administration, as it was formerly known). Fleming and John Iglehart, founding editor of the journal, moderated the discussion.

HIV/AIDS

The Syringe Access Fund, a collaborative funding partnership of the Irene Diamond Fund, Elton John AIDS Foundation, Levi Strauss Foundation, and National AIDS Fund awarded forty-six grants, according to a February 2010 e-alert. “Created in 2004 to support direct services and public policy activities to reduce the risk of HIV and other blood-borne diseases often transmitted through injection drug use,” the fund is the “largest nonprofit funder of syringe exchange programs” in the United States. Read more here about the fund’s sixth round of grants.

Related resource:

“Fighting HIV/AIDS in Washington, D.C.,” Alan E. Greenberg of the George Washington University et al., Health Affairs, November/December 2009. Shannon L. Hader, senior deputy director, HIV/AIDS Administration, Department of Health, Washington, D.C., is among the coauthors.

Philanthropy News

“Can Failure Be the Key to Foundation Effectiveness?” Bob Hughes of the RWJF, on the Center for Effective Philanthropy Blog, 11 January 2010. Among those foundations “sharing what they have learned about things that didn’t work” are the RWJF and the Bill & Melinda Gates Foundation. Hughes gives some reasons why foundations’ honesty about failed programs can be beneficial. This post generated some buzz—online comments and Tweets. I (as well as others, I would guess) would like to know what grantees think of this openness, especially if they have had unsuccessful projects.

Merck’s recent merger with Schering-Plough means that the two health care companies’ charitable activities have also merged. Because of this, the Merck Company Foundation has expanded its New Jersey Neighbor of Choice program, which helps groups in New Jersey communities where Merck facilities are located. Based in the Garden State, the foundation is a national and international funder; however, it does “not accept or respond to unsolicited proposals.” Read more here about the Neighbor of Choice grants.

Philanthropy Journal announced that it has become a program of North Carolina State University’s Institute for Nonprofits. However, the e-publication “will be self-sufficient” and will not be supported by state funds, according to a January 2010 e-mail from its editor and publisher, Todd Cohen. Multiyear gifts were to come to the publication from its main funders, the A.J. Fletcher Foundation and the William R. Kenan Jr. Charitable Trust, he said.

Public Health

“Creating a Healthier Colorado Requires an Attention to Public Health,” Richard F. Hamman, founding dean of the Colorado School of Public Health, in the Colorado Health Foundation’s Health Relay blog, 8 April 2010. In this post to coincide with Public Health Week (5-11 April 2010), Hamman points out that in addition to health care, “clean air and water, safe, healthy food and a healthy environment” are important to creating “a healthier community Throughout the state, “our current public health workforce is gr[a]ying,” he says.

Health-Related Costs from Foodborne Illness in the United States, a report from a Pew Charitable Trusts initiative, estimates such illness costs the United States $152 billion annually. Robert L. Scharff—formerly an economist at the Food and Drug Administration (FDA) and now an assistant professor at the Ohio State University—authored this report from the Produce Safety Project at Georgetown University, released 3 March 2010. The report found that Hawaii, Florida, and Connecticut are the three states with the highest costs per case. Read more here about Pew’s work in food safety. Also see the interactive map showing state-by-state costs, based on the report and developed by the Make Our Food Safe coalition and advocacy group. The report is timely, as the House of Representatives passed a food-safety bill in July 2009, and a separate Senate bill was unanimously approved by the Senate Committee on Health, Education, Labor, and Pensions in November 2009. A spokesperson handling the report told Health Affairs that the Senate’s bill may go before the full Senate during the last week of April 2010.

“State and Local Health Departments: Doing More with Support from Foundations,” a 15 February 2010 Issue Focus from Grantmakers In Health, says that “there are many opportunities for foundations to work with and strengthen state and local health departments” during a time when these departments “are asked to take on more responsibilities with fewer resources.” See examples of what funders have supported.

Related resource:

“Agricultural Policy and Childhood Obesity: A Food Systems and Public Health Commentary,” David Wallinga of the Institute for Agriculture and Trade Policy (in Minneapolis), Health Affairs, March 2010.

American Foundations: Roles and Contributions has recently been published by Brookings Institution Press. Helmut K. Anheier and David C. Hammack edited this 450-page volume.

Overview of the Book

The product of a three-year project supported by the Aspen Institute’s Nonprofit Sector and Philanthropy Program, the volume provides the most comprehensive assessment to date of the significance and impact of the nation’s large foundations. In its eighteen chapters, leading researchers explore how foundations have shaped–or failed to shape–each of the key fields of foundation work. Chapters draw widely on published and unpublished sources. (The published sources are, in fact, much more extensive than is often suggested.) Several of the chapters also rely on analysis of the Foundation Center’s database containing basic information on nearly 150,000 grants made in 2001. American Foundations takes the reader on a wide-ranging tour, evaluating foundation efforts in education, scientific and medical research, health care, social welfare, international relations, arts and culture, religion, and social change.

 Each contribution to this volume stands on its own, but all authors considered a standard set of questions. To what extent do foundations emphasize Relief of Immediate Needs, Philanthropic Innovation, or Control of Charitable Assets? What roles do foundations play?

 With regard to meeting immediate needs or providing basic services, all contributors agree that foundation resources are much too limited to substitute for government or the market and that foundations can complement government only to a very limited extent.

 With regard to philanthropic innovation, it is clear that whereas there was a classic era in which the Carnegie, Rockefeller, Rosenwald, and several other foundations could create entirely new institutions and even fields, foundation resources are now in almost all cases insufficient for such grand initiatives. Foundations can now join campaigns to change social perceptions, foster recognition of new needs, encourage the empowerment of the socially excluded, explore new directions for policy, and stimulate social entrepreneurship.

 To an extent that usually goes unacknowledged, foundations also control charitable assets, by supporting charitable and religious institutions and seeking to preserve cherished values and traditions—religious as well as secular.

Because their resources are dwarfed both by the profit-seeking economy and by government, foundations are simply not able to play the role of redistributing wealth. Foundations do play the roles of entrepreneur, institution builder, risk absorber, and broker. And foundation actions are sometimes fairly criticized for insufficiency, particularism, paternalism, and amateurism.

Overall, editors David Hammack and Helmut Anheier say in the concluding chapter that foundations play an essential part in the philanthropic activity that does much to define the United States. Making use of their great freedom, foundations pursue an extraordinary variety of aims. The editors write:

Americans have criticized foundations for . . . their alleged conservatism, liberalism, elitism, radicalism, devotion to religious tradition, hostility to religion—in short, for commitments to causes whose significance can be measured, in part, by the controversies they provoke. Americans have also criticized foundations for ineffectiveness and even foolishness.

 They conclude:

Throughout the history of U.S. foundations, there has been a persistent and significant mismatch between aspiration and available resources—a discrepancy that continues and is even widening today. . . . In the second and third decades of the twentieth century a very few foundations were indeed sufficiently wealthy, . . . yet the foundation experience of that relatively short and unsettled period continues to cast a shadow on current perceptions and practices. By contrast, the experience of more recent decades shows that foundation resources—despite significant growth and despite the vast resources added to the field by the Bill and Melinda Gates [Foundation] and other foundations—are quite limited, relative to their ambitions, and are likely to remain so for the foreseeable future. Given this persistent mismatch between objectives and means, it is no surprise that foundations have rarely made contributions, positive or negative, on their own; rather, they work, typically and necessarily, in some form of partnership.

 As for the book’s editors, Anheier is dean of the Hertie School of Governance, in Berlin, Germany; academic director of the Center for Social Investment at Heidelberg University; and professor of public policy and social welfare at the University of California, Los Angeles (UCLA). His publications include Creative Philanthropy, written with Diana Leat (Routledge, 2006) and Nonprofit Organizations (Routledge, 2005)

 Hammack is Hiram C. Haydn Professor of History at Case Western Reserve University, in Cleveland, Ohio, where he also is a leader of the Faculty Council of the Mandel Center for Nonprofit Organizations.

 Chapter on Foundations and Health

 Daniel M. Fox, president emeritus of the Milbank Memorial Fund, wrote the book’s chapter titled “Foundations and Health: Innovation, Marginalization, and Relevance since 1900.” Dan shared with the GrantWatch Blog some selected excerpts (with minor edits) from the chapter.

The ideas, political skills, and cash of the donors, directors, and staff of American philanthropic foundations have affected the health status of millions of people during the past century. Foundations in health have innovated and temporized. They have sustained some organizations, promoted radical change in others, and helped to invent more than a few. They have embraced public advocacy and avoided it. In doing their work in health, foundations have collaborated as well as contended with leaders in government, universities, hospitals, and the medical profession.

This chapter assesses the influence of leading foundations on health policy and practice. I define “leading foundations” as those whose trustees, staff, and money had, at least for some years, effects that can be documented on significant issues in health affairs, nationally, as well as internationally. Some of these foundations have been among the largest endowments; others have been middle-sized; a few have been relatively small.

Most foundations, unlike these leaders, have been passive donors to health care organizations. They mainly responded to proposals to meet the immediate or short-term needs of medical schools, research organizations, hospitals, and—in the first four decades of the twentieth century—patients. Moreover, as the health sector grew to become the largest sector in the American economy, foundation giving declined in relative importance to spending by government, employers, and individual consumers.

I summarize the history of the leading foundations in health during the past century in three words: innovation, marginalization, and relevance. From the early twentieth century through the 1920s, leading foundations collaborated on innovation with central actors in health policy and practice. They planned and implemented new ways to organize education for the health professions, basic and clinical research, and the delivery of services in hospitals and ambulatory settings. From the early 1930s through the 1980s, the work of leading foundations, though respected by central actors in health policy and practice, was marginal to the major issues that preoccupied them. Since the early 1990s, the work of leading foundations has been consistently relevant to major issues in health policy and practice in the United States and of growing importance in the area of global health.

The principal finding of this chapter is that foundations influenced the resolution of significant health problems when their goals were congruent with the goals of key decision makers in health affairs and when these decision makers judged foundation staff to be trustworthy and their cash to be helpful. Foundations have sometimes helped to make history, but they have rarely made it themselves.

Two Other Chapters to Check Out

The book also includes a chapter titled “The Robert Wood Johnson Foundation’s Efforts to Improve Health and Health Care for All Americans,” which was written by James R. Knickman, formerly of the RWJF and now president of the New York State Health Foundation, and Stephen L. Isaacs, president of Health Policy Associates, in San Francisco, and a partner in Issacs/Jellinek, a consulting firm that advises foundations.

There is also a chapter on “Foundations and Public Policy” by Steven Rathgeb Smith of the University of Washington’s Evans School of Public Affairs.

On April 8, the Rhode Island Foundation hosted Sarah Iselin, president of the Blue Cross Blue Shield of Massachusetts Foundation, who spoke on “Bending the Curve: The Challenges of Cost Containment.”

This was the third presentation in the foundation’s “Making It Work: Health Reform in Rhode Island series.” The goal of the series is to help Rhode Islanders agree on the right questions for the state to ask as it decides how to implement health reform.

Challenges and First Steps

Iselin’s presentation took the series another step down the road as she laid out some of the challenges and first steps of cost containment in Massachusetts. She presented data that showed that without intervention, per capita heath care spending in Massachusetts was projected to double by 2020 to an unsustainable $17,872 per person.  Although that figure is staggering, she laid out some of the first steps of rolling the cost containment rock uphill. Massachusetts has passed and begun to implement legislation that has laid the groundwork for that state’s cost conversation.

Two pieces of legislation have helped define statewide cost and quality goals and implementation mechanisms and have created the Special Commission on the Health Care Payment System to investigate how to reform the payment system to provide incentives for efficient and effective patient-centered care and reduce variations in the quality and cost of care. As part of that effort, the commission has estimated that if three potential opportunities for savings were fully realized, the state could save as much as $1.5 billion. Although those three big-ticket items–potentially preventable emergency department (ED) visits, preventable hospitalizations, and potentially preventable readmissions–would be hard to achieve, “there’s big money there,” Iselin said. “Some would say those savings are teeny ‘compared to the 30 percent waste,’ etc., but there are lots of opportunities to achieve significant savings.”

Commission’s Vision

Iselin then moved to the commission’s vision of how Massachusetts could move away from a fee-for-service payment system that drives health care cost growth and overuse of services and toward a more patient-centered “global” payment system. The commission’s recommendations include: participation by all payers; encouraging development of integrated provider entities; payment systems that reward performance and promote quality of care and cost transparency; medical home models that organize patient-centered care; and development of a state oversight entity. The committee recommended the state transition to this new system over a five-year period. New legislation would be required to create the state entity and move forward.

Report on Cost Drivers

In late March 2010, following up on a requirement of the 2008 Massachusetts legislation, the state’s attorney general issued a report on the cost drivers in Massachusetts’ system. Iselin said this report, which is an example of “perfect transparency,” now allows citizens to see what providers charge and what insurers pay. One of the  things that stand out most in the report is the wide variability in costs—most of it seemingly driven by hospitals’ and providers’ dominance in local markets. According to Iselin, “this kind of data is promoting a whole new dialogue about what markets can do and what government can do.”

Politics

Illustrating the difficulty of moving forward in “a political environment that is incredibly loaded” is the current dispute between insurers and the state. When insurers submitted annual requests for rate adjustments, the vast majority were rejected. The insurers have now filed suit against the state, contesting the grounds used to deny the requests.

“This is why we did coverage first, because cost-containment is really hard,” Iselin said. “A lot of trust has been built up–we have the lowest rate of uninsured folks in the country and we’re proud of that–but this has frayed it a little.” She commented, “The consensus is [that] we all have to work together for the long-term, but the politics are really complicated.”

Leading off the Rhode Island Foundation’s “Making It Work: Health Reform in Rhode Island” series was T.R. Reid, the author of The Healing of America, who argued that all countries must make a moral choice about who gets care and who doesn’t. Then, Deborah Chollet of Mathematica Policy Research and independent consultant Deborah Faulkner reported on a foundation-commissioned study projecting that 140,000 Rhode Islanders would be without health insurance coverage in March 2010 (moreover, 187,000, or 21 percent of the state’s population, are projected to be uninsured at some point this year).

With the recent passage of federal health reform, GrantWatch Blog has gathered here a sampling of foundation leaders’ comments on reform, examples of what foundations have funded on this topic, and related resources.

Foundation Leaders’ Statements on the Patient Protection and Affordable Care Act (H.R. 3590)

“The Health Reform You Haven’t Heard About,” Robert K. Ross, president and chief executive officer (CEO) of the California Endowment, Bob’s Blog, 30 March 2010. Ross says, “This reform is the civil rights bill for the sick,” and it “also catalyzes the transformation from sick care to true health care.” Another interesting point he makes is that “the final draft of the bill has more than 200 Republican amendments in it,” so whatever people may say, it is a “product of bipartisanship.”

“A Major Step Forward for Better Health and Health Care,” Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation (RWJF), 23 March 2010, RWJF’s Users’ Guide to the Health Reform Galaxy blog. In this statement, Lavizzo-Mourey says that “the new law meets core principles for coverage set down by the Foundation and offers the country the opportunity to improve the health of our people.” She quotes Tom Kean, board chair of the RWJF and former Republican governor of New Jersey, here: “What’s so important about foundations like ours is that we have the long-term perspective to keep our eye on the horizon and stay above the fray, the partners and knowledge to get the job done, and the resources to stick with issues over the long haul.”

“A New Era in American Health Care,” Karen Davis, president, and Sara R. Collins, vice president, Affordable Health Care, of the Commonwealth Fund, Commonwealth Fund Blog, 22 March 2010. The authors maintain that “the legislation will put the U.S. health system on a path to high performance, by providing for the testing of new ways of paying doctors and hospitals to reward results rather than fees based on the volume of services delivered and for the development of strategies to promote prevention and improve quality.”

“A New Outlook for Achieving Access to Health for All Coloradans,” Irene M. Ibarra, president and CEO of the Colorado Trust, 24 March 2010. She wrote this for the trust’s new CommunityConnections Blog. Ibarra outlines the role of the Colorado Trust now that the federal legislation has been inked.

“What Will Federal Health Reform Mean for California? Reaction from the California HealthCare Foundation,” 22 March 2010. This article mentions some of the positive effects expected from the legislation, such as “dramatically” increasing the number of people with health insurance. However, paraphrasing Mark Smith, president and CEO of this California funder, the article cautions that “things may get worse before they get better.” For one thing, some of the major provisions of the health reform legislation do not kick in until 2014.

“Statement from NYSHealth on the Passage of Federal Health Care Reform,” Jim Knickman, president and CEO of the New York State Health Foundation, 22 March 2010. Knickman says that the legislation has numerous strengths; he cautions, though, that its “ultimate success” will greatly depend “on the work done to implement its reforms.” He acknowledges that improvements can be made to the law, and he hopes that “they emerge on a bipartisan basis.”

Poll on Health Reform

“It Passed. So What’s in It?” Pew Research Center for the People and the Press, released this News Interest Index survey on March 31, 2010. Conducted in late March, it found that 55 percent of members of the public polled “say they understand at least somewhat well how the new health care law will affect them and their families.” This center is a project of the broader Pew Research Center, a nonprofit, nonpartisan subsidiary of the Pew Charitable Trusts—a public charity.

Report on Consumer Advocacy and Reform

Building on the Foundation: Consumer Advocacy’s Role in Successful Health Care Reform Community Catalyst, a nonprofit consumer group in Boston that “is committed to changing the health care system through consumer empowerment and engagement” issued this report “to highlight the challenges and opportunities” for consumer advocacy groups and their funders in the “post-reform environment.”

Rob Restuccia, Community Catalyst’s executive director, said in an accompanying letter, “We wrote the [January 2010] report from the viewpoint that national health care reform [would] be enacted upon soon.” Among the report’s “key takeaways” is that “states will be a central focus” of health reform activity; “new tools and greater community engagement are required to address health disparities;” and “the advocacy infrastructure at the state and national levels will need to be strengthened to ensure effective consumer participation in the process,” he said.

The report suggests several strategies for advocates: (1) building public support for reform and “working for successful implementation of the [reform] provisions that go into effect immediately;” (2) defending existing programs (such as Medicaid) and their current coverage levels; (3) “developing policy and regulations at the national and state levels;” (4) “enrolling people in new programs and monitoring the impact of reform;” (5) “ensuring the sustainability of reform” through delivery system reform that constrains “overall health care spending in the United States.”

Advocacy groups must collaborate, the report adds. Suggestions on this front include “increased coordination among funders to ensure effective application of limited resources, and between funders and advocates to develop shared agendas and strategies based on local environments and needs.” The Public Welfare Foundation funded this report.

$26.5 Million in Grants to Health Care for America Now

“Advocates Plot Next Steps Even as Ink Dries on Health-Care Overhaul Law,” by Suzanne Perry in the March 23 Chronicle of Philanthropy reports on a $26.5 million grant from Atlantic Philanthropies to Health Care for America Now (HCAN), “a coalition of more than 1,000 liberal advocacy groups and labor unions.”

Also, read “A Big Bet on Advocacy Helps to Make History on Health Care,” a column by Gara LaMarche, president and CEO of Atlantic.

On March 11 I heard LaMarche speak at the Grantmakers In Health meeting in Orlando. In his speech he mentioned Atlantic’s large amount of funding for HCAN, so that its member groups could compete more against the “big lobbyists;” the view was that advocacy for health reform needed strengthening. Because it is a Bermuda-based foundation, Atlantic was able to do this. Other funders of HCAN included the California Endowment, Open Society Institute, and individuals.

LaMarche said that Atlantic had learned from its work in other countries about organizing around an issue and had learned to “put an issue on the agenda and keep it there.” He also noted that Atlantic has decided to spend all of its assets [by 2020], because it wants to do more good now by focusing “concentrated resources” on efforts it supports. The foundation, however, accepts only invited proposals, he noted. LaMarche’s speech will be posted soon on Atlantic’s Web site, a spokesperson told GrantWatch Blog.

Related Resources on Reform

Some recent Health Affairs Blog posts analyzing the reform bill and its passage include:

“Eight Rules from The Heart of Power: How Did Obama Do?” Jeff Goldsmith of Health Futures, Inc. (http://www.healthfutures.net), 29 March 2010.

“The Health Care Reform Reconciliation Bill (Updated),” Tim Jost of Washington and Lee University School of Law, updated as of 20 March 2010.

Other resources of interest:

“New Health Initiatives Put Spotlight on Prevention,” Robert Pear, New York Times, 4 April 2010.

“Summary of Coverage Provisions in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010,” Henry J. Kaiser Family Foundation, 5 April 2010.

Bill and Melinda Gates Foundation Pledged $10 Billion in a Call for a Decade of Vaccines

In case you missed this announcement, the Bill and Melinda Gates Foundation said that it “will commit $10 billion over the next 10 years to help research, develop and deliver vaccines for the world’s poorest countries.” The press release noted that “increased vaccination could save more than 8 million children by 2020.” The foundation pointed out, however, that “significant funding gaps remain,” so “major new funding” is needed from donors, governments, and the private sector. The announcement was made at the World Economic Forum’s Annual Meeting, which was held in Davos, Switzerland. Much background information, including a video of the press conference at which the Gateses announced this huge commitment to vaccines and the “2010 Annual Letter from Bill Gates” (which focuses on vaccines) is available here.

Ruth Levine, formerly of the Center for Global Development (CGD) and now with the U.S. Agency for International Development (USAID), discusses how the Gates Foundation will leverage its commitment of billions. In a post titled “Daddy Healthbucks: How Will the Gates Foundation Leverage the New $10 Billion for Vaccines and Immunization?” on the CGD’s Global Health Policy blog, Levine expects, she says, “that the Gates Foundation will use [its] resources in ways specifically designed to leverage others’ investments, and to lower the costs of getting vaccines to market and then to kids and teens.” She then includes a list of what the foundation “maybe” will do, but makes it clear that her list is “pure speculation.” One interesting suggestion she has for the foundation is “to create a 10-year Global Health Policy Fellows program, modeled on the Robert Wood Johnson Foundation Health Policy Fellows [program], to place mid-career global health professionals within Congressional and Executive branch offices.” She explains: “No amount of advocacy from the outside for health aid can replace dedicated, value-adding expertise on the inside.” The fellows “would be the next generation of policy movers and shakers.”

Levine received several thoughtful comments on her post. For example, Robert Steinglass of JSI Research and Training Institute, Inc., noted that a few of those commenting focused “on the critical issue of ensuring that once vaccines arrive in country, they do indeed reach their intended beneficiaries.” Despite the many obstacles in some countries, “promising interventions and innovations for immunization service delivery are also taking place under difficult circumstances,” he states. One doesn’t hear much about this good news, at least in Africa, Steinglass commented. Toward that end, he reported that the Gates Foundation had awarded a grant to the JSI institute for a project called Africa Routine Immunization System Essentials (ARISE), which he directs.

Health Affairs Articles on Vaccines:

For more information on vaccines, read these Health Affairs articles, published in 2009: “Why We Don’t Have an HIV Vaccine, and How We Can Develop One,” by Jeffrey E. Harris of the Massachusetts Institute of Technology (MIT); “Polio Eradication: Strengthening the Weakest Links,” by Scott Barrett, formerly of the Johns Hopkins University, and now at Columbia University; and Dinesh Sharma’s review of The Vaccine Narrative by Jacob Heller.

In addition, see Health Affairs, May/June 2005, a thematic issue on “The Vaccine Enterprise.” View the Table of Contents for that issue.

Other Resources:

“Measles Resurgence Tied to Parents’ Vaccine Fears,” Richard Knox, National Public Radio, 5 April 2010.

Also, on 17 February 2010 the nonpartisan Partnership for Prevention highlighted vaccine news in its blog called Prevention Matters. Each week the blog contains a feature called “Best, Worst Prevention Ideas of the Week.”

Best idea: “Lancet Finally Retracts Study Linking MMR, Autism” was a Prevention Matters post about this journal’s retraction in early February of its 1998 article saying that there was a link between the measles-mumps-rubella (MMR) vaccine and autism. The Lancet is based in London.

Worst idea: “Millions of U.S. Adults Behind on Immunizations.” Here, the blog links to a recent report released by Trust for America’s Health (TFAH), the Infectious Diseases Society, and the Robert Wood Johnson Foundation. Although the report contains some discouraging news, it also includes several policy recommendations.

Vaccine Research

Interested in seeing some of the research that is under way? Visit the following Web sites:

Aeras Global TB Vaccine Initiative, which is “developing new tuberculosis vaccines for the world” and is funded by the Gates Foundation, the Mary Lynn Richardson Fund, and others.

International AIDS Vaccine Initiative (IAVI), which receives funding from the Gates Foundation, New York Community Trust, Rockefeller Foundation, and others.