Sustaining and Extending Health Care Reform: Perspectives on the ACA from California


February 28th, 2012
by E. Richard Brown

GrantWatch Blog invited E. Richard Brown, a professor at the University of California, Los Angeles, School of Public Health, to report some highlights from a February symposium on health reform.

“Health care reform is not self-implementing,” said Peter Long, president and chief executive officer (CEO) of the Blue Shield of California Foundation, as he led off the UCLA Center for Health Policy Research’s recent symposium on “Sustaining and Extending Health Care Reform.” Some 290 people attended the event; the audience included policy staff and advocates, as well as researchers. Long captured the message of all of the symposium speakers who emphasized the opportunities and challenges in developing policies aimed at getting all eligible people enrolled in coverage that meets their needs for affordable, high-quality health care and improves their health.

During one panel discussion, Anthony Wright, executive director of Health Access of California, a large consumer advocacy coalition, noted that the Affordable Care Act is not only the largest expansion of health care coverage in more than a generation. It is also the largest advance ever in creating a patients’ bill of rights, because it puts a national floor under protections that will help people get and keep affordable coverage, he said. The Affordable Care Act also at least attempts to make patients the focal center of health care services. But getting there will require forceful leadership to go up against powerful interest groups and a political system that they dominate, he explained.

Kimberly Belshé, one of five governing board members of the new California Health Benefit Exchange, emphasized that the exchange has a short timeframe in which to develop a consumer-centered process with “no wrong door.” (Belshé was secretary of the California Health and Human Services Agency from 2003 to 2010 and is now a senior policy adviser at the Public Policy Institute of California.) By January 1, 2014, the exchange must be ready to enroll adults and children in private health insurance and public programs, provide them subsidies if they are eligible, and ensure that they can readily access health services that they need. The California legislature, as in about half the states that have established exchanges thus far, gave the exchange the power, and a mandate, to be an “active purchaser” of health insurance by selectively contracting with health plans that meet its standards.

Achieving Kim Belshé’s vision would require converting the current system to one with a new mission—to get everyone into affordable, high-quality coverage, and this will require monumental changes in private health insurance and Medicaid alike, each of which will provide about half the national gains in coverage. Medicaid eligibility and enrollment processes were designed almost fifty years ago, mainly to keep out adults who did not fit one of the narrow federal welfare categories—extremely poor adults who were in a family with dependent children, or those who were disabled or older than age sixty-five.

The Affordable Care Act turns that orientation on its head. California’s Health Benefit Exchange must now create a new user-friendly system that welcomes all and ensures that they are enrolled in affordable coverage that meets their health care needs, whether it’s the Medicaid program (Medi-Cal) or private health insurance. Unfortunately, the Affordable Care Act prevents state exchanges from serving undocumented immigrants; in California there are two million undocumented people, more than half of whom are uninsured. Their care will be left to their own resources and overburdened local health care safety nets.

The big change required from Medicaid will have to be concurrently matched by a transformation of the current private health insurance market for individuals and small groups, an unfriendly and largely “caveat emptor” environment. The Affordable Care Act and California state implementation legislation make clear that the exchange is expected to create a regulated marketplace designed to protect consumers from high-cost, low-value health plans. The exchange’s active purchaser powers enable it to begin transforming this marketplace. In addition, an initiative that is likely to be on the California ballot in November would give health insurance regulators the power to set rates.

All of the speakers at the symposium emphasized the important and necessary changes that the Affordable Care Act has set in motion, and also the immense challenges that face those charged with implementing it, particularly at the state level. The changes attempt to modify coverage and health service delivery incentives that now strongly favor the interests of insurers and providers, changes that will require these actors to pay closer attention to the needs of patients, improve health outcomes, and be more affordable. The challenges are the vested interests of those insurers and providers and the clout they wield in health policy.

Diana Bontá, president and CEO of the California Wellness Foundation, and Robert M. Kaplan, director of the National Institutes of Health’s Office of Behavioral and Social Sciences Research, both emphasized at the symposium that the Affordable Care Act’s larger goal is to improve the health of the population and reduce social disparities in health outcomes. Improving population health will require more than the clinical preventive services that the federal health reform law now makes more accessible. More fundamentally, it requires broad social policies that promote healthy eating and active living through policy changes and that reduce inequalities in income and wealth through redistributive policies.

Editor’s note: The symposium honored the work of the UCLA Center for Health Policy Research, as well as the work of E. Richard Brown, founding director emeritus of the center, who wrote this post.

Challenging the Policy of Disdain for Chronically Homeless People


February 24th, 2012
by Paul Gionfriddo

Foundations should provide leadership in programming and advocacy for this population.

In the early 1990s, there was a movie entitled Dave. Kevin Kline stars in it as the head of an employment agency who happens to look exactly like the president of the United States.

When the president has an incapacitating stroke as he cheats on his wife with a White House aide, his chief of staff (who shares the president’s cynical contempt for the American people) isn’t ready to turn over power to the more compassionate vice president. So he recruits Dave to play the role of the president until the chief of staff can arrange for a transfer of power to himself.

Dave grows in the role because he has a big heart and a kind soul. He is especially moved when he is invited by the First Lady to visit a shelter for the homeless.

He is stunned to see a shelter full of children. “Children are homeless, too,” the First Lady reminds him. Right then and there, Dave decides to do something about the problem.

Children account for more than one third of the homeless population, and it’s hard not to be moved by this. Dave’s Cabinet—a room full of other well-intentioned men and women—rallies to his side in the movie. Other budgets are cut so the shelters can get their funding, and everyone is happy except the irate chief of staff.

If only life imitated the movies. . . .

We still have far too many homeless children in America, but the problem of chronic homelessness isn’t usually about kids. And it isn’t quite so easy to get funding to help chronically homeless adults.

Many in this population have drug addictions or psychoses that have prevented them from finishing school and working. Some have served in the military and have returned from battlefields with physical and psychological scars. Most have at some point appeared on our street corners and highway exit ramps, sometimes begging for food and money.

We neither sympathize nor empathize with them.

Perhaps that is why federal funding for Homeless Assistance Grants decreased by 28 percent between 1995 and 2005. Or why the homeless assistance program in Pennsylvania was cut by 10 percent last year, and why Pennsylvania Gov. Tom Corbett (R) proposed cutting it by 20 percent more this year. Or why Gov. Rick Scott (R) of Florida proposed cutting all funding from homeless programs in his 2011 budget and vetoed $12 million of funding for homeless veterans that was approved by the state legislature. Or why Gov. Andrew Cuomo (D) proposed cutting funding for youth shelters to balance the New York State budget in 2011. Or why Alabama proposed new cuts this year to supported housing for people with mental illness who could become homeless.

We don’t see that chronically homeless adults are somebody’s parents, children, and best friends from childhood, and that they are often very ill.

According to a factsheet from the National Coalition for the Homeless, more than one-quarter of the sheltered homeless population has serious mental illness—more than four times the percentage in the regular population. Nearly one-third of homeless adults has an addiction disorder. Some two-thirds of the single homeless are male. Forty percent of homeless men are veterans. Approximately half of homeless women and children have been victims of violence at home.

This doesn’t always move policy makers the way that the image of homeless children moved Dave in the movie. As one Florida state senator commented recently, “When it comes to funding, an 85-year-old woman in a nursing home matters more to me than a 45-year-old guy with a substance abuse problem.”

So how do we go about investing in the future of people whose lives are devalued in this way?

We start by recognizing that life-altering chronic conditions are not character flaws, and an eighty-five-year-old with serious disease isn’t more or less worthy of our help than a forty-five-year-old with serious disease. They both need it.

Then we need to issue a challenge to the policy of disdain.

The Conrad N. Hilton Foundation has been a leader in that effort for more than two decades. It has invested $60 million in programs to end chronic homelessness. Its funded partner, the Corporation for Supportive Housing, has helped communities develop more than 150,000 supportive housing units during the last decade. This successful relationship was highlighted in a GrantWatch article in the May/June 2009 issue of Health Affairs.

Supporting people with chronic conditions has reduced chronic homelessness–even as the prevalence of some serious mental illnesses like post-traumatic stress disorder (PTSD) has risen. Community supportive housing initiatives have been credited with helping reduce chronic homelessness by 13.5 percent between 2007 and 2011.

The national alliance Funders Together to End Homelessness has also focused on finding solutions to the problem of chronic homelessness. Now 122 members strong, Funders Together offers tools and resources to funders on the front lines of the fight against chronic homelessness. More than a dozen United Ways and more than a dozen more community foundations are among its local members, along with a host of regional and national funders. Funders involved in this group include the California Endowment, which has invested $2 million in creating 900 supportive housing units, and the Frey Foundation of Minnesota, which has invested $5 million in supportive housing and services in the Twin Cities.

We didn’t create the problem of chronic homelessness overnight. Short-sighted public policies that emptied state hospitals without providing adequate funding for community living have contributed to it for more than three decades.

And we won’t fix it by pretending that the chronic diseases that often cause chronic homelessness aren’t as real and life-threatening in children and young people as they are in elders. We need funders and others working together to challenge our misperceptions.

And we need them to fund advocacy groups to help educate policy makers about at least three ways to help prevent chronic homelessness among adults: preserving, not cutting, funding for adult mental health and addiction services; expanding, not contracting, support services for returning veterans and their families; and making safe shelter for all a national goal.

The author has an adult son with mental illness who is chronically homeless.

Where Has All the Grant Money Awarded Gone? How Grantors Tell Us Their Post-Grant Stories


February 21st, 2012
by Hope Leman

In this post, an observer of foundations who writes from Oregon offers some suggestions of how funders could improve their communications about results of grants.

Ever wonder who gets grants and what those grants have funded? It is often surprisingly hard to find out. And it is even more surprising, given the importance for grant makers of conveying to various audiences their success in fulfilling the grantors’ respective missions, that so few use their web sites to highlight what exactly was funded, in what amounts, and what resulted from those grants.

This topic has been on my mind since mid-2008, when I began to work on ScanGrants, a free online service listing funding opportunities in the health sciences.

Since that time, I have spent thousands of hours visiting the web sites of major philanthropic organizations, small foundations, disease advocacy groups, scientific societies, professional organizations, and occasionally the sites of health sciences journals. Indeed, I view the web sites of practically any group that offers funding opportunities (for example, clinical research grants; grants for programs in community, behavioral, or public health; scholarships for conference attendance, professional development, or associate-level, undergraduate, or graduate studies; fellowships; or essay awards) in medicine and health.

My work at ScanGrants leads me most often to sites of foundations that fund research or professional education of individual investigators.

This is very rewarding work, and I never cease to be amazed and moved by the generosity of the funders and the stories behind some of the gifts (such as when a scholarship is created in the name of a particularly beloved patient or when a prize for scientific achievement is named for a pioneering physician). And, certainly, the sums of money I have read about are substantial—such as grants in the millions for cancer or neuroscience research.

Naturally, I often wonder what becomes of all that money. I often pause during my workday to ponder this. I look for the personal stories of the grantee and the population he or she helped, or how the grantee otherwise used the funds for professional development and, thereby, for the good of society. Sadly, I often seek in vain for the anecdotal side of the world of philanthropy.

As a casual visitor to a funder’s site, one is often left with little notion about the rest of the story. What a missed opportunity on many levels—the good of the funder’s reputation as a public benefactor or an agent of real change, and the foregone chance to tell inspiring stories about research and the career success of those dedicating their lives to science or the betterment of society in general. After all, you never know who may visit your web site: the chance to interest that one bright high school student (and future social worker or Nobel Prize winner) in your cause is always there.

My advice also applies to other funders whose stories might be about the success of a community program, instead of the success of a talented individual.

So who are the master storytellers out there when it comes to narratives about funded projects? Who tells a compelling (or at least a detailed) story?

Not surprisingly, given its reputation as an innovator in grant making in health and health care, the Robert Wood Johnson Foundation offers a model of accountability in its Retrospective Series, a series of reports that not only illustrate what the RWJF has focused on and accomplished via grant making but also are themselves beautifully produced and make a genuine contribution to the subject at hand (for example, end-of-life care or tobacco-cessation programs). The foundation provides these reports in a handy PDF format on its web site, free to all.

Granted, not every grant-making organization possesses the financial wherewithal or subject-area expertise that the RWJF does. Still, it is increasingly easy to produce fairly nice-looking reports in a PDF or e-book format, and, thus, not doing so is a lost opportunity from a marketing, accountability, and messaging standpoint.

And if a grantor does not have the staff or other resources to put together a glossy report, at the very least, a list (on its web site) of recent grants with such details as the purpose of the grant, the amount given, and the name and location of the grantee is de rigueur. Here, again, the RWJF provides a model, as does the Commonwealth Fund.

The Commonwealth Fund’s web site also provides downloadable, completed grant reports. (These are mainly for its own use, but they also benefit those interested in how health policy funders operate.)

As it states, “Memoranda prepared by Fund staff on completed grants are key to ensuring the accountability of the foundation’s grantmaking process and execution of program strategies. It is important that these memoranda not only document project outputs but also attempt early assessments of impact. These documents, which are archived, will be important to future historians of American philanthropy….The Commonwealth Fund’s practice of systematically examining all Board-level and Small Grants Fund projects completed in the course of a year, scoring them on performance and other measures, and preparing a report that draws out lessons learned provides valuable insights for program development, management, and communication [staff] and helps promote accountability throughout the Fund.” Such candid discussions of what was hoped for and what actually occurred are commendable vis-à-vis transparency and the literature of grantsmanship.

And, speaking of candor, at the state level, the Kate B. Reynolds Charitable Trust, the mission of which is to improve the quality of life and quality of health for the financially needy of North Carolina, does an admirable job in providing a frank assessment of the success of its programs, much to the benefit of grantees and those whom they and the trust want to help. Check out the downloadable reports on the Evaluation and Research page of the trust’s web site.  

Since writing the above, I have surfed and clicked around in the world of grants, and as I end this post, I am more convinced than ever that grantmakers need to take a look at their web sites and pretend they are first-time visitors. Can such visitors find out easily the answer to the question, “Where has the previously awarded money gone?” That is, ”Is it clear that our grants are making a difference in the lives of real people and that our grants have improved things, somewhere, tangibly? What is better because of our programs? What specific person or program was able to accomplish something concrete because of us?” Oftentimes, those questions are unanswered, to the detriment of both the visitor to the site and to the reputation of the funder.

Okay, so who excels on their web sites at answering that key question, “Where has the previously awarded money gone?” Well, the Aetna Foundation clearly lists grants and their purpose and provides links to the reports and articles that resulted. This foundation has a succinct, but impressive roster of tangible accomplishments and contributions to health research.

Finally, foundations should not be shy about profiling those to whom they have given scholarships, for example. Often it is the story of a young person who might never have gotten the chance to go to medical school that is so compelling. Dry statistics about “our programs” take the funder only so far. Tug my heartstrings!  Do the same with grantees at a higher level (such as researchers funded).

For example, even though most foundations lack the deep pockets of the Bill & Melinda Gates Foundation, check out the Grantee Profile of African Women in Agricultural Research and Development. (This profile is actually part of its Global Development Program.)

Now, that is a well laid-out page. It provides the particulars of the grant program and includes a video showing the people who got the grants, the places they live, the projects they are engaged in, and the people the grantee and grantor are trying to help. As the cost of video production declines, don’t dismiss out of hand featuring on your site a video describing a project. After all, “In this video, meet three African agricultural scientists whose research is helping small farmers to find solutions to their production challenges and create better lives for their families” is fairly straightforward narrative and could be emulated at the community level by small foundations here in the United States.

Personalize, personalize, personalize. And when you’re creating content, make sure I can download it, e-mail it, tweet it, bookmark it, pin it on Pinterest, and otherwise share it through the ever-increasing number of social media venues. Keep me on your site by making it “sticky.”

Tell me a story.

What in the World Is a Health Home?


February 13th, 2012
by Tom David

The author explains the concept and how it can help safety-net patients. David also alerts us to the Health Home Innovation Fund, managed by Tides’s Community Clinics Initiative and funded by the California Endowment. He thanks Jane Stafford, managing director of the initiative, for her help with this post.

Among the many provisions of the Affordable Care Act, one of the most intriguing–and confusing—is that health care providers should move toward providing “health homes” for their patients. What does that mean in practice? It’s certainly not an image that immediately resonates with most people, particularly those who have traditionally sought care from the health care safety net. 

To gain insight into how patient-centered models of care are emerging in the safety net, my Community Clinics Initiative (CCI) colleagues and I talked with more than thirty innovative providers and payers around the country. (The California Endowment supports this initiative of Tides.) Here’s what we learned from our discussions. 

A variety of concepts have been proposed, ranging from “patient-centered medical homes” to “person-centered health homes” to “community-centered health homes,” to name but three. Although they share many of the same qualities, for now we prefer the more generic image of a ”health home.”

In our opinion, health home projects offer a more expansive view of health promotion and improvement than more physician-centric medical home concepts. Such projects also acknowledge that medical care alone will be insufficient to ultimately achieve health equity for underserved populations. Patient and family engagement and self-management are seen as essential complements to clinical interventions. A health home prioritizes the voice of the patient and sees culturally sensitive prevention and primary care as the cornerstone for an integrated system of care.

How do we get there from here? Fortunately, there is much experience and wisdom around the country to draw on. The Commonwealth Fund’s Safety Net Medical Home Initiative has already developed excellent assessment tools and resource guides to aid practice transformation. Many valuable lessons have been learned about the complex challenges of implementing electronic health records and reconfiguring practice teams and workflow at providers in safety-net settings. There’s no need to reinvent those wheels!

But we’ve been struck by how often the discussion among professionals jumps over the question of what “person-centeredness” might look like from a consumer perspective and instead focuses on detailed prescriptions for redesigning practice from a provider perspective. The focus also tends to be on primary care, rather than on connecting different providers and resources into an easy-to-navigate system of care. Prevention and social determinants of health are also rarely part of the conversation.

To try and integrate all these potential pieces into a single image of a health home, we developed this diagram

  

Part of the challenge in talking about health homes is that we believe some combination of all these concepts are often part of the conversation, whether acknowledged or unacknowledged, at least among professionals. But when most consumers think about what they’d want in a health home, we suspect that the innermost circle (or two) is often what they’re talking about.

The center of the diagram portrays the doorway to the health home from a consumer perspective. What are consumers looking for? Based on our work with health centers and consumers across California, we speculate that they would likely list the following as priorities: respect in all interactions; friendly faces who know them and speak their language; convenient, attractive locations and hours; and a personal relationship with a provider they trust. 

The next circle out (Enhanced Access) is often not at the top of the priority list of desired changes for providers but is very salient for consumers. Just like privately insured patients, safety-net patients want same-day appointments, after-hours access to urgent care, an advice line or online connection, and no long waits when they come in for care.

The next circle out (Person-Centered Medical Home) is where most of the energy of providers in innovative practices is going.  It builds on the principles of provider teams, panel management, and patient self-care inherent in the Chronic Care model, informed by appropriate health information technology systems, such as electronic health records.

The fourth circle, “Integrated Care and Prevention,” takes the basic patient-centered medical home model to a higher level of integration, incorporating behavioral health, oral health, and other special resources such as a dietician and pharmacist in the primary care setting. It also promotes wellness and patient self-care via support groups, one-on-one coaching, and exercise and cooking classes. Much effort is devoted to health education, including the use of innovative technologies to facilitate patient self-management at home or at work.

We have appropriated the “Accountable Care Organization” label for the fifth circle, to signify the importance of connecting primary care settings to specialty care, hospitals, and other elements of the health care system in as seamless a fashion as possible. This has long been a gaping hole in the safety net of most communities. Just exchanging data among clinics and hospitals has been impossible in most places. From a consumer perspective, ease of navigation of these elements of the system is key but highly problematic at present. The interoperability, shared risk, and accompanying financial incentives integral to the accountable care organization concept will need to be put in place on a regional level if the health home concept is to be financially sustainable.

Finally, medical care and patient self-management alone will not be sufficient to advance health. It will take a shared commitment to primary prevention, including healthy environments and access to healthy food and safe housing, as well as advocacy to address other social determinants of health and wellness, to achieve the ultimate goal of providing a true health home.

We have used this diagram as the starting point for a two-year grant-making program we are calling the Health Home Innovation Fund. With funding from the California Endowment, the Community Clinics Initiative is supporting ten partnerships around California to build health homes for their local safety-net populations.

We recognize that the fully developed health home we have just described remains an aspirational goal at present. But regardless of the eventual fate of the Affordable Care Act, the stage has been set for fundamental change in the way American health care is organized and financed. As a wise person observed at one of our recent meetings, “Everyone’s business model is up for grabs.” Just as market forces are driving consolidation across the for-profit landscape, we believe it’s essential that the organizations comprising the health care safety net seize this opportunity for experimentation and innovation. If we are to ever achieve the goal of health equity and also bend the cost curve, the time has come to connect the disparate elements of the safety net into a truly integrated system of care.

Philanthropy People Post: Foundation Folks on the Move


February 10th, 2012
by Lee-Lee Prina

Read about some comings and goings at foundations and an appointment to the Institute of Medicine.

Ned Calonge, president and chief executive officer (CEO) of the Colorado Trust, was elected to the Institute of Medicine (IOM) in October. A physician, Calonge is a former medical director for the state of Colorado and is on the Colorado Health Institute’s board. “Election to the IOM is considered one of the highest honors in the fields of health and medicine, recognizing individuals who have demonstrated outstanding professional achievement and commitment to service,” said Colorado Trust board member Reginald Washington in a November blog post.

Phillip González has been appointed program director of Community Catalyst’s Roadmaps to Health Community Grants. Community Catalyst, located in Boston, is a national, nonprofit, consumer advocacy organization that is dedicated to high-quality, affordable health care for all, according to a December press release. González was previously director of grant making at the Blue Cross Blue Shield of Massachusetts Foundation. He has been employed at Community Catalyst before—as director for the Philanthropy and Physician Diversity projects.

Trevor Mundel has been named the new president of the Bill and Melinda Gates Foundation’s Global Health Program; he started at the Seattle-based funder in December. He formerly was global head of development for Novartis Pharma AG and was based in Basel, Switzerland. According to a press release, Mundel’s job is to lead the Gates Foundation’s efforts to develop and deliver drugs, vaccines, and other tools to fight diseases found in the developing world, such as HIV/AIDS, tuberculosis, and malaria, and to “take the world closer to the goal of polio eradication.” 

In September, Margaret O’Bryon, president and CEO of the Consumer Health Foundation, will be stepping down as leader of this funder—the Washington, D.C., region’s first private health foundation. She has been in this position since the foundation started—in 1998. After she officially departs from the foundation, she will remain involved as a part-time senior strategist. A December press release notes that O’Bryon has been “locally and nationally recognized for her commitment to social justice, health equity, and activist philanthropy.”

In other Consumer Health Foundation news, Julie Farkas, senior program officer, resigned from the foundation recently, according to the foundation’s Winter 2011 newsletter. Farkas worked there for twelve years and was the foundation’s first program officer. The newsletter mentioned her work as being “characterized by excellence, passion, energy and extreme dedication.” She is now working with CollegeTracks and Impact Silver Spring, two nonprofits in the Washington, D.C., area.

Last, but not least, Ria Pugeda recently joined the staff of the Consumer Health Foundation as a program officer. She also has worked for the Public Welfare Foundation.

Carl Schramm, president and CEO of the Ewing Marion Kauffman Foundation, announced in January that he had decided to step down from his position at the Kansas City, Missouri–based funder. He served as the foundation’s leader for nearly a decade and decided “to return to scholarship and business,” according to a press release. It noted that Schramm will be available during the transition to new leadership. Benno Schmidt, a member of Kauffman’s board of trustees, is serving as interim president and CEO.

Chris Stone has been named the next president of the Open Society Foundations, established by investor George Soros. Stone, who will start in his new position in July, is now the Guggenheim Professor of the Practice of Criminal Justice at Harvard University’s John F. Kennedy School of Government, as well as director of the Hauser Center for Nonprofit Organizations, also at Harvard. Stone will succeed Aryeh Neier, who has led the Open Society Foundations since 1993. Neier announced in 2011 that he would be stepping down from his post. See a list of the Open Society Foundations initiatives here. They include its Global Drug Policy Program and its Public Health Program.

New In the Journal: How Foundations Are Helping States Implement Health Insurance Exchanges


February 9th, 2012
by Lee-Lee Prina

This GrantWatch column in the just-released February 2011 issue of Health Affairs is full text, free access, to all readers.

As many of you are aware, under the Affordable Care Act of 2010, individuals and small businesses, as of 2014, will be able to compare health insurance plans and enroll in them through state-based marketplaces called exchanges. (See the column for some other helpful features of exchanges.)

The federal health reform law’s intent is for each state to run its own exchange, but the law also gives states an “out”: either partnering with the federal government on an exchange or letting the federal government run it for the state.

The GrantWatch column I wrote for that issue discusses how foundations around the country have been working to help states make decisions about and establish their health insurance exchanges—for individuals and/or small businesses.

The column first discusses national efforts, such as that of Community Catalyst’s Affordable Care Act Implementation Fund. Foundations supporting that initiative include the Atlantic Philanthropies, California Endowment, Nathan Cummings Foundation, Ford Foundation, Jacob and Valeria Langeloth Foundation, and Rockefeller Foundation.

GrantWatch also mentions a number of projects funded by the Robert Wood Johnson Foundation, as well as an exchange-focused section of the Henry J. Kaiser Family Foundation’s gateway web page called Health Reform Source. And there is more: I mention a Commonwealth Fund grant, and a report cofunded by the California Wellness Foundation and others.

Foundation-funded efforts in several states are also described. California, Colorado, Kansas, Missouri, New York, Ohio, and Rhode Island are highlighted. I mention how far these states have, or have not, progressed in establishing an exchange, as of December 28. The challenge in writing such a column is the possibility of having the information “overtaken by events,” a phrase I learned from my Dad. This is because, with exchanges, the situation in the fifty states is fluid, and states are at varying stages in their preparations.

Among the funders mentioned in the “State Efforts” section are the California HealthCare Foundation, Colorado Health Foundation, Sunflower Foundation, Missouri Foundation for Health, New York State Health Foundation, Health Foundation of Greater Cincinnati, Rhode Island Foundation, and many more.

This is just a sampling of foundations’ efforts, not a comprehensive list! If you know of other funders that have been supporting development and implementation of exchanges, please let me know—either by commenting below or sending me an e-mail, lprina@projecthope.org.

For information on states’ activities on exchanges, see the Kaiser Family Foundation’s factsheet that was updated January 18. Its map of state exchange efforts is current as of January 30.

Key Personnel News

The February GrantWatch column also includes some “people news.” Read about the new head of Grantmakers In Aging; the new president of the Greenwall Foundation, which now focuses solely on bioethics; the passing of Margaret (“Maggie”) Mahoney; and more.

Also in the February issue of Health Affairs:

Read about a cluster of articles, supported by the Commonwealth Fund, on Small Business Health Care Options Program (SHOP) exchanges. This type of exchange was authorized under the Affordable Care Act. Authors include Tim Jost, a professor at Washington and Lee University law school and a frequent blogger on Health Affairs Blog, and Jon Kingsdale, founding director of the Massachusetts Connector Exchange.

Round-up of Foundation Blog Posts: Neglected Diseases, Health Reform, Wellness, and More


February 2nd, 2012
by Lee-Lee Prina

Every few weeks I do a round-up highlighting a few recent posts from foundation blogs that have caught my eye. Topics this time are global health (specifically, neglected tropical diseases), health reform, wellness, and lessons learned by a seasoned funder.

Global Health/Neglected Tropical Diseases

“Tackling Neglected Tropical Diseases,” by Julie Jacobson, on the Bill and Melinda Gates Foundation’s Impatient Optimists blog, January 28. Jacobson, a senior program officer for infectious diseases in the Gates Foundation’s Global Health Program, alerts people to the announcement that the Gates Foundation and more than a dozen global pharmaceutical companies, as well as some donor countries, non-governmental organizations (NGOs), and others, have formed a partnership to assist people around the world who suffer from neglected tropical diseases, including schistosomiasis and onchocerciasis (river blindness). The goal? By working together, the partnership aims to control or eliminate ten such diseases by 2020.

There have been some successes in the past in combating these diseases—for example, the Carter Center’s work against guinea worm disease (Jacobson’s description of this condition is not for the squeamish!). The funders of that work have included the Gates Foundation and Conrad N. Hilton Foundation. (Please note that this link goes to some lessons learned; the Hilton Foundation’s program in that area has concluded.)

But much work remains to be done, Jacobson says. And through this innovative partnership, the various partners, which have been combating these diseases for many years, can increase the effects of their individual investments. “The simple fact is, working together, we can achieve far more than any one of us could on our own,” she comments.

For more details, read the Gates Foundation’s January 30 press release.

(Jacobson comments that most people have not heard of neglected tropical diseases. Admittedly, I had never heard of these illnesses before I came to work at Health Affairs. Back in 2008, for example, I ended up writing about a Gates-funded network to prevent trachoma and other diseases.)

Related resources:

Health Affairs thematic issue on Meeting HIV/AIDS Costs and on Neglected Diseases, November/December 2009. Read the Table of Contents. Authors include Adel Mahmoud and Elias Zerhouni; Phil Musgrove (the journal’s late deputy editor) and Peter J. Hotez; and Gerry Anderson.

New World Health Organization (WHO) strategy on neglected tropical diseases, released January 30.

Fodder for Funders: Lessons Learned

“Good Judgment Comes from Experience. . . and Experience Comes from Bad Judgment,” by Chris Langston, health AGEnda blog of the John A. Hartford Foundation, January 26. Here, Langston, Hartford’s program director, candidly writes about lessons learned by this national funder focusing on the health of older Americans. This post would be useful to both private and public funders. Langston says he will proudly compare the Hartford Foundation’s record with anyone’s, but most of the demonstration efforts it has funded “have failed to influence practice widely, therefore failing to meet OUR objective for them: to improve the health of older Americans.”

He says that “good ideas are not enough.” One also needs to arrange for technical assistance and tools to help the ideas take off, as well as the right “attitudinal, regulatory, and financial conditions under which [the ideas] can grow and flourish.” His suggestions include “plan for challenges.” He mentions the Hospital at Home program, spearheaded by the foundation and Johns Hopkins School of Medicine, and he says that he wishes the foundation had allocated funding for “stand-by capacity.” He notes that at times there was an inadequate supply of home care clinicians to deliver this intervention for geriatric patients.

He also recommends funding “the best evaluation you can afford.” A good evaluation is very expensive, he notes, “but it is an investment that you can draw upon for years and years.” For example, an adequate sample size is important. He asks, “If you don’t believe in what you are [evaluating] enough to want to do it right, are you sure you should do it at all?”

Health Promotion and Disease Prevention/Wellness

“Wellness Innovators in Somerset County [Maine],” Barbara Leonard, on the Maine Health Access Foundation (MeHAF) Blog, January 18. Leonard, MeHAF vice president for programs, writes about the Micro-Wellness Project for Small Businesses, which is partially funded by MeHAF. Somerset County, Maine, the site of the statewide foundation’s work, is nearly four times the size of Rhode Island, and Maine is home to many small businesses. Small firms in Somerset County participating in the project include a law firm, a print shop, and a grist mill, Leonard explains. The Greater Somerset Public Health Collaborative has teamed up with entities including the local chamber of commerce’s wellness council and a hospital; they aim to create a “virtual wellness program” for rural small businesses.

Wellness incentives, funded by grants, are one feature of this model—the goal being to mimic what larger businesses offer via insurance coverage. (Grant funds are also being used “to model the tax credits that are to become available” to small businesses through the Affordable Care Act, Leonard explained to me in an e-mail.) In the wellness project, Somerset County small businesses can use centralized, shared resources, such as wellness coaches and health risk appraisals, the blog post says.

Related resources:

“Explaining Health Care Reform: How Will the Affordable Care Act Affect Small Businesses and Their Employees?” Henry J. Kaiser Family Foundation, January 2012.

Watch for a cluster of papers on Small Business Health Options Programs (SHOPs) in the February 2012 issue of Health Affairs, which is scheduled to be released on February 8.  Under the federal health reform law, health insurance exchanges will operate a SHOP beginning in 2014. (Read more here. )

Health Reform

“Falling in the Gaps of Health Reform,” Sandy Graham, on the Colorado Health Foundation’s Health Relay blog, January 24. In this post, Graham, who is project manager and managing editor of the foundation’s informative, four-color Health Elevations publication, illuminates an interesting point about the Affordable Care Act with a personal anecdote. Graham had assumed that her daughter, “an underemployed college graduate” who is no longer a full-time student, could be covered under the family’s health plan. Not so! The reason? Their insurance coverage is for retirees, not regular employees, of a large company. When Graham researched this further, she learned that, in fact, “retiree-only plans [do] not have to comply” with the Affordable Care Act’s provision extending coverage for young adults up to the age of 26 on a parent’s plan, she explained. Read the post to find out the legalities of this and how this family found reasonable coverage for the daughter. Learn something new every day, they say, and I did!

Why a California Foundation Filed an Amicus Brief with the U.S. Supreme Court


February 1st, 2012
by Robert K. Ross

The head of one of the largest private foundations in the United States, the California Endowment, explains how it came to the decision to show its support for the constitutionality of the federal health reform act.

Nearly everyone would agree that greater access to health care for all Californians is a good thing. As the nation’s most populous state, California is also, coincidentally, the state with the most uninsured people—more than 6.9 million uninsured adults and children. Let’s face it: if all of those people were to have a major medical crisis, the costs to the health care system and to society would be astronomical. In fact, the reality is that national costs are already remarkable: uncompensated medical care of uninsured persons was estimated at $62.1 billion for 2009.

The core of the California Endowment’s mission is to expand high-quality health care to all Californians, and to achieve that, we need better and more affordable access to health care, particularly for those in working class, underserved, and low-income communities. That’s why the California Endowment, by way of Kathleen Sullivan, an esteemed Supreme Court litigator, acted on clear legal ground in filing a second amicus brief with the U.S. Supreme Court in support of the constitutionality of the Affordable Care Act of 2010. This second brief strengthens the data and information found in our first brief supporting the constitutional argument referring to the minimum coverage requirement (or individual mandate) found in the federal health reform law.

As a backdrop, the Endowment sponsors social science and public policy research that increasingly provides evidence to policy makers and consumers about the benefits of expanding access to affordable, high-quality health insurance. We were compelled to share this wealth of research that contends that the inclusion of the minimum coverage requirement in the Affordable Care Act, which would drastically reduce the number of uninsured and reduce spiraling health care costs, is perfectly within Congress’s authority under the Commerce Clause of the U.S. Constitution.

The Supreme Court has repeatedly reaffirmed that Congress has broad authority to regulate interstate commerce. As such, the Affordable Care Act’s regulation of the distribution, purchase, and consumption of health services—economic activities that make up 17.6 percent of gross domestic product—falls squarely within allowed Commerce Clause regulation. The key connection here is that the failures in the health care market—high, uncompensated costs—are tangibly linked to commerce, so the federal health reform law, which includes a mandate on minimum coverage, is Congress’s attempt to address that failure. And the minimum coverage requirement would, indeed, have corrective properties: it would expand the pool of the newly insured by at least 2 million in California alone.

The California Endowment felt no hesitation in getting involved with this important issue, for the principal reason that the Affordable Care Act will be a huge catalyst in reforming the broken health care system as we know it. Many people are already benefiting from its provisions: seniors are getting help paying for medications, young people are able to stay on their parent’s health coverage policy up to age twenty-six, and parents are able to get health coverage for their children who were previously denied it because of a pre-existing condition. And in 2014, the health reform law will expand access to public and private health coverage to millions of Americans—many of whom are struggling right now to get the medical care they need. For those Americans, 2014 can’t come too soon.

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