Health Affairs

As a former state legislator and foundation CEO, I worry about how the majority opinion of Chief Justice John Roberts on the constitutionality of the Affordable Care Act of 2010 (National Federation of Independent Business v. Sebelius) may affect our approach to prevention programs. Funding environmental health may be the best way to go.

In its ruling on the individual mandate, the court came down hard against the authority of the federal government to tell individuals what they can or cannot do. In its ruling on the Medicaid expansion, it limited the federal government’s ability to “coerce” states to accept new national health programs by threatening to withhold federal dollars for existing programs.

Both of these court rulings could influence the way that funders think about public health and prevention in the future, as well as the sustainability of prevention programs they begin.

There are really only two ways to do prevention, and both have champions in the funder community.

The first option is to focus on individuals—that is, to get them to change their behaviors. A national example is the wonderful Let’s Move program, a joint effort of First Lady Michelle Obama and the Partnership for a Healthier America.

However, despite this (recent) compelling call to action…

Over the past three decades, childhood obesity rates in America have tripled, and today, nearly one in three children in America are overweight or obese. The numbers are even higher in African American and Hispanic communities, where nearly 40% of the children are overweight or obese. If we don’t solve this problem, one third of all children born in 2000 or later will suffer from diabetes at some point in their lives. Many others will face chronic obesity-related health problems like heart disease, high blood pressure, cancer, and asthma. (Source: Let’s Move website).

…the Let’s Move campaign is essentially just promoting lifestyle change through education–and, clearly, nothing in a court decision limiting federal mandates on individuals and states is going to open the door to much more.

The second option for funders is to focus on communities—that is, to change the environments in which people live. When people hear the phrase “environmental health,” they usually first think of big things like climate change, ozone depletion, carcinogenic chemicals, and oil spills in ocean water. But numerous examples of community-level environmental health programs can be found in the work of members of the Health and Environmental Funders Network (HEFN) or the Environmental Grantmakers Association. Read the rest of this entry »

My GrantWatch column in the August 2012 issue contains a selected sampling of foundation funding on the topic of the health care safety net. Grants awarded include efforts to help safety-net providers, as well as populations who turn to the safety net for their health care.

The column is but a small part of the journal’s thematic issue on “challenges facing the safety net.” The Blue Shield of California Foundation provided support for the publication of the issue. A number of the articles in the issue focused on research studies that were supported by foundations.

Community clinics:

Community clinics are an important part of the safety net. Read about a major Commonwealth Fund initiative with Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute. This five-year Safety-Net Medical Home Initiative has numerous cofunders including the Blue Cross Blue Shield of Massachusetts, Boston, Colorado Health, Jewish Healthcare, and Northwest Health Foundations; Blue Cross of Idaho Foundation for Health; Beth Israel Deaconess Medical Center; and Partners HealthCare. Read the rest of this entry »

Two staffers at a Kentucky foundation report on a webinar held in July to address this important question.

Today, grantmakers and some government agencies are encouraging public health departments and nonprofit health promotion organizations to “advocate for policy change,” but the line between permitted advocacy and prohibited lobbying is often unclear. The Centers for Disease Control and Prevention (CDC) recently issued guidance regarding how federal grantees can use their funding to promote programs, systems, and policies that support healthy individuals and communities, and since 2005, health funders have had a resource to help identify advocacy skills. At the Foundation for a Healthy Kentucky, we are working to make the line between advocacy and lobbying a little brighter and clearer and to provide added training on advocacy skills.

The Foundation for a Healthy Kentucky (the legacy foundation resulting from the conversion of the statewide Blue Cross plan in Kentucky to a for-profit entity) is a nonprofit philanthropic organization that invests in communities and informs health policy through grant making, research, and education. With a mission to address the unmet health care needs of Kentuckians, the foundation is committed to policy work that can improve access to care, reduce health risks and disparities, and promote health equity. We focus on issues and conditions that present major challenges to the health of the people in Kentucky, and we seek local solutions to these challenges. As a “learning organization,” we are committed to evaluating the impact of the work that we fund. 

As part of its mission, the foundation provides funding and technical assistance to community groups that are working to improve the health of Kentuckians. Through these efforts, an army of advocates is emerging, helping to give voice to populations and communities not often heard in the policy debate. To support this work, the foundation has developed a series of webinars and in-person workshops. The series, titled Health for a Change, is free and open to the public. The target audience is staffers of organizations that seek to be effective health policy advocates. 

The Foundation for a Healthy Kentucky’s July 11 webinar—Advocacy? Lobbying? Know the Difference!—was conducted by Nayantara Mehta, senior counsel for the Alliance for Justice’s Bolder Advocacy initiative. Mehta cited the situation that many advocates face as they seek to transform health policies and, at the same time, sustain their operations with philanthropic and government grants. Because federal funding and many foundation grants prohibit lobbying, advocates must develop messages and activities that do not violate these terms. Mehta demonstrated how advocates can carefully craft messages that encourage action on a policy issue without disobeying the Internal Revenue Service (IRS) lobbying rules or those of a funder’s contract—by omitting any direct instruction to “call your legislator” about a specific bill. Read the rest of this entry »

Upon receiving the news “you have cancer,” there are many questions that run through a patient’s mind, key among them: Where can I get the best care?  Today, meaningful information to help patients answer this question is lacking.This post is based on remarks that the author made on July 12, in Los Angeles, at the California HealthCare Institute’s meeting entitled “California: Uniting Science and Policy to Advance Cancer Care.” Stephanie Teleki is a senior program officer at the California HealthCare Foundation.

Some Choices, So Little Information

In most cases, patients have choices about where to receive cancer care, albeit with limitations and trade-offs. It is typically only when there is a rare diagnosis that there may be just a few places to go for treatment.

In choosing a provider for cancer treatment, a patient’s first stop is usually somewhere familiar—their medical group or their health plan. To help patients select a cancer care provider, these entities mainly offer directory-style guides that include information such as hospital and medical group name, location, and contact information. These directories sometimes offer more data on physicians—for example, medical specialty, medical school attended, and whether the practice is open to new patients. However, there is usually little-to-no information about the quality of care provided.

This is not just a problem for patients. Physicians and health plans also lack such quality of care data. For example, typically, the referring physicians may only know whether their past patients “liked” a particular oncologist or surgeon, but popularity based on characteristics such as good bedside manner does not necessarily correlate with clinical excellence.     

Patients who look for other resources to help them find a suitable provider will find ratings of different types of providers (hospitals, medical groups, individual doctors) on a wide variety of websites, including Medicare.gov, Consumer Reports, HealthGrades, and Yelp, to name a few. Notably lacking across these sources is valid, reliable information about two aspects of cancer care that are vitally important to patients: the outcomes of cancer care (the survival “bottom-line”) and other patients’ experiences with given providers.

So, while there is seemingly an abundance of information about cancer care, a scratch below the surface reveals very little that actually helps cancer patients determine where they will receive the highest quality of care. If a patient has connections or is especially good at executing literature searches of scientific publications and understanding the results, he or she may be able to find out who is a famous cancer researcher, but the patient will be hard pressed to find out who is good at delivering clinical care.

When it comes to cancer care, knowing who is good is critical. Getting to the well-known provider (who may not actually be that good at clinical care) could mean frequent long-distance travel requiring support that patients may not have (for example, child care or transportation) and high expenses (going “out of network”)—this adds more burden to an already burdensome disease. Being able to weigh—with meaningful information—whether these types of sacrifices are worth it matters a lot. Read the rest of this entry »

In July, just before the International AIDS Conference here in the Washington, D.C., area, the Merck Company Foundation announced its new HIV Care Collaborative for Underserved Populations in the United States. Read on to find out what this corporate foundation is supporting. The post also contains some information about a few other foundations funding in the HIV/AIDS area.

The Merck Company Foundation (a foundation funded entirely by Merck, the pharmaceutical company) announced this three-year, $3 million initiative that has awarded grants to local health departments in the Atlanta, Houston, and Philadelphia metropolitan areas. The aim of the HIV Care Collaborative is to “connect more people living with HIV in these high-burden communities to the care they need to stay healthy,” according to a July 19 press release. Why is this important? “Research shows that when you are able to connect those who are HIV-positive with ongoing care, it not only reduces HIV risk behaviors but also reduces viral load,” the company’s website says. Thus, the care with antiretroviral drugs ultimately contributes “to overall decreases in HIV transmission.” The focus is on “helping to ensure that people living with HIV gain access to timely care and treatment that they need to remain healthy,” Leslie Hardy, vice president of the foundation, explained to me in an e-mail. In the public health world, this is called “secondary prevention.”

For example, Houston and surrounding Harris County, one of the HIV Care Collaborative’s sites, will launch a communitywide effort “to identify all those living with HIV who have fallen out of care and re-engage them,” the press release said. The Atlanta/Fulton County site will have a linkage coordinator, who will aim to link clients (who have been referred from the county’s HIV Primary Care Clinic) to available services. Philadelphia is going to use system navigators to help guide patients with HIV through the local health care system.

The foundation pointed out that its initiative aligns nicely with the Obama administration’s National HIV/AIDS Strategy for the United States. How? The initiative aims to help achieve one of the national strategy’s objectives: “establish a seamless system to immediately link people to continuous and coordinated quality [of] care when they learn they are infected with HIV.” This is actually Step 1 under the national strategy’s broader goal of “Increasing Access to Care and Improving Health Outcomes for People Living with HIV.” Read the rest of this entry »

The Colorado Health Foundation hosted a debate on July 25 as part of its annual Colorado Health Symposium. The conference sold out, as it has many other years. GrantWatch Blog asked Chuck Reyman, vice president of communications at the foundation, who organized the debate, to write a post sharing his observations.

Statistically speaking, there’s not much controversy as to whether obesity is a serious problem in the United States. Data from the National Health and Nutrition Examination Survey shows that more than one-third of adults and 17 percent of youth were classified as obese in 2009 and 2010. In addition, the medical community is sounding the alarm over the dramatic increase in type 2 adult-onset diabetes in obese children.

Nor are there many arguments about whether obesity is costly (a recent article from the Obesity Journal estimates the nation’s cost of obesity may be as high as $147 billion annually—approximately 9 percent of all U.S. medical spending). Another article forecasts that if obesity levels were to plateau at 2010 levels, the combined savings in medical expenses over the next two decades would be $549.5 billion.

What is subject to controversy, however, is whether federal, state, and local governments should take a more active role or retreat to the sidelines in regulating fat- and sugar-laden foods.

We are beginning to see some of that debate play out in the public square. In 2007, New York City issued a first-ever law restricting artificial trans fats in restaurants. Since then, other cities have followed suit. Last year, New York City Mayor Michael Bloomberg proposed an outright ban on large servings of sodas. Elsewhere, municipalities such as El Monte, California, have weighed imposing a “soda tax” as a disincentive for consumers to indulge in sugary beverages (this also gives cities a much-needed revenue stream from those who continue to imbibe these “liquid candies”).

Depending on your perspective, the government’s role in determining what we eat is either a necessary intervention or a blatant intrusion on American free will. With the controversy percolating in town hall meetings, the airwaves, and the blogosphere, the Colorado Health Foundation decided to host a food policy debate as part of its 2012 Colorado Health Symposium.

With a tip of the hat to the movie National Lampoon’s Animal House, we titled this year’s debate “Food Fight! Who Gets to Decide What Our Kids Get to Eat?” and turned our panelists loose on the following resolution: “Resolved: Healthy eating is a function of personal choice and should not involve government regulation.” Read the rest of this entry »

GrantWatch Blog invited Jim Tallon, president of the United Hospital Fund, a nonprofit health services research and philanthropic organization, to blog about a recent “health reform and philanthropy” event held in Manhattan and his thoughts on the topic. Tallon, a policy leader himself, was a member of the New York State Assembly for nineteen years. He chaired the health committee from 1979–87 and was majority leader from 1987–93. 

While the Supreme Court’s decision on the Affordable Care Act (ACA) is being parsed across the country for its impact on individuals, institutions, and states, for philanthropies large and small—both those focused on health care and those with other interests—there may be very different meanings. That’s why Philanthropy New York brought together five of us—an economist, a journalist, a consumer advocate, a government official, and a policy leader—in mid-July for a discussion, led by a foundation leader and witnessed by both on-site and online audiences, about the ACA’s implications and the opportunities it opens up.*

The richness of the presentations can’t be captured in this commentary, but all agreed that the Supreme Court’s ruling balanced ideological division and pragmatic compromise, affirming a vision of substantial but incremental health care reform—neither the single-payer aspirations of the left nor the competitive-market approach of the right. Simply stated, 30 million Americans stand to gain insurance coverage, while increased attention to care coordination, payment incentives, information technology, and patient engagement aim to reduce the rate of health care cost growth—a fundamental challenge to economic security. Beyond those givens, discussants’ views were more varied, however.

For me, it seems clear that—unlike the emerging political consensus on health care reform of less than a decade ago—deep divisions today shape both presidential and congressional campaigns and presage an end-of-year congressional debate on taxing, spending, and deficit issues, and perhaps on the ACA itself. The initial rejection of a largely federally funded Medicaid expansion by a number of governors marked the transition from a debate about program design to one on the goal, itself, of expanding insurance coverage among low-income Americans. Read the rest of this entry »