TOWARDS TRANSFORMATIVE CHANGE IN HEALTH …...philanthropy and a fine leader in philanthropy more...

A Philanthropy at Its Best® Report

TOWARDS TRANSFORMATIVE CHANGE IN HEALTH CAREHigh Impact Strategies for Philanthropy By Terri Langston

About the AuthorTerri Langston is an independent consultant in Washington, D.C. She works on the local,regional and national levels on health reform implementation, issues surrounding poverty, andadvocacy to bring the voices of all people into work promoting equity. She was a program offi-cer, director of programs and senior program officer for health reform at the Public WelfareFoundation from 1987 through 2010. Ms. Langston served as a board member of GrantmakersIn Health from 1996 to 2003. She holds a Ph.D. from Emory University and was a FulbrightScholar to Germany in 1981–1982. In 2008, she was the recipient of the Terrance KeenanLeadership Award in Health Philanthropy awarded by Grantmakers In Health.

AcknowledgementsThe author thanks her many colleagues in health philanthropy over the years who haveexchanged ideas and mutual support and have become better grantmakers with each passingyear. Special thanks go to Sara Kay of The Nathan Cummings Foundation for her incisive per-spectives on the endeavors of health grantmaking and Susan Sherry of Community Catalyst,ever the one to bring considerations back to the people in communities where the work willmake a real difference. Margaret O'Bryon of the Consumer Health Foundation, Phyllis Kaye ofthe Regional Primary Care Association and the Health Working Group of the WashingtonRegional Association of Grantmakers have been of critical help to the author. The advisorycommittee for this report consists of dedicated professionals who were generous with theirinsights at an extremely busy time for everyone. Grantmakers In Health is the leader of healthphilanthropy and a fine leader in philanthropy more broadly. The author thanks Lauren LeRoyfor her leadership and for her insights concerning this report. Finally, the National Committeefor Responsive Philanthropy has the courage of its convictions, a characteristic needed by bothorganizations and individuals now more than ever, and I hope it will continue to display thatcourage. The author thanks Aaron Dorfman for his leadership and for giving her the opportunityto work on this report. It has been a particular pleasure to work with Niki Jagpal, research andpolicy director – to learn from her worldview, to endure her exacting editing and questions,and to gain a new friend with such admirable values.

FundingNCRP operates with the financial support of more than 60 different foundations, and some ofthose grantmakers are mentioned in this report. A complete list of funders is available on ourwebsite, www.ncrp.org.

Cover Photos — Bottom Left:As many as 5,000 people are estimated to have participated in Seattle's March andRally for Health Care Reform on May 30, 2009. Photo Credit: Neil Parekh/SEIU Healthcare 775NW. Bottom Right:President Barack Obama delivers remarks on the health insurance reform bill at the Department of Interior, March23, 2010. From left, Vice President Joe Biden, Vicki Kennedy, wife of the late Sen. Ted Kennedy, and 11-year-oldMarcelas Owens of Seattle, Washington. (Official White House Photo by Pete Souza)

Table of Contents

Executive Summary ..................................................................................................................1

I. Introduction............................................................................................................................3

II. Communities: People in Context..........................................................................................6Race and WealthExemplary Foundations Employing a Contextual Lens in Health Grantmaking

III. The Non-System of Health Care ........................................................................................10The Path to Health Reform: Community organizing, coalition building and advocacy

IV. The Affordable Care Act ....................................................................................................13Expansion of Coverage to Lower-Income PeopleInsurance ExchangesDelivery System ReformWorkforceTransforming Public Health

V. Other Opportunities for Reform Across the System ..........................................................21The Triple Aim: Grantmaker-Supported Delivery Reform Toward Integrated CareChronic Disease and Public Health: The Business CaseThe Safety Net

VI. An Economic Necessity ....................................................................................................26

VII. Towards Transformative Grantmaking ..............................................................................28

VIII. Making this Report Relevant to Your Foundation ..........................................................31Current Trends in Health Grantmaking

IX. Conclusion ........................................................................................................................41

References ..............................................................................................................................42

Advisory Committee

Judy Feder CENTER FOR AMERICAN PROGRESS

Phillip Gonzalez BLUE CROSS BLUE SHIELD OF MASSACHUSETTS FOUNDATION

Laura Goodhue FLORIDA COMMUNITY HEALTH ACTION INFORMATION NETWORK (CHAIN)

Anthony B. Iton THE CALIFORNIA ENDOWMENT

Sara Kay THE NATHAN CUMMINGS FOUNDATION

Richard Kirsch ROOSEVELT INSTITUTE

Lauren LeRoy GRANTMAKERS IN HEALTH

Lorez Meinhold OFFICE OF THE GOVERNOR OF COLORADO

Jennifer Ng’andu NATIONAL COUNCIL OF LA RAZA

Margaret O’Bryon CONSUMER HEALTH FOUNDATION

Debra J. Perez ROBERT WOOD JOHNSON FOUNDATION

Susan Sherry COMMUNITY CATALYST

Alan Weil NATIONAL ACADEMY FOR STATE HEALTH POLICY

Wendy Wolf MAINE HEALTH ACCESS FOUNDATION

Katherine Villers COMMUNITY CATALYST

Organization affiliation for identification purposes only.

Executive Summary

Our nation confronts vast differences inhealth outcomes that manifest themselves inone community to the next. Our unequalhealth care system has left us at a pointwhere we can predict health and longevityby a person’s zip code. Externalities includingdiscrimination, institutional power and neigh-borhood conditions have a greater effect onhealth outcomes than do disease, injury ormortality. Poverty and the unequal distribu-tion of wealth remain closely associated withunhealthful conditions.

Simultaneously, the American people seekhealth care from a system that is fragmented,inefficient and costly to the point of beingeconomically unsustainable. Viewed broadlyin terms of the interdependence of societyand of the overall health of residents, the cur-rent health system ultimately is not benefitinganyone.

Despite these conditions, people in com-munities nationwide are making decisions onways to improve their own health outcomesas well as those of their children. Foundationssupport many of these activities throughplace-based initiatives that work with peoplein the context of their communities.Alongside those efforts, leaders of health sys-tems, hospitals, community-based serviceand advocacy organizations are transformingthe health care system and are poised to domore as part of the implementation of thehealth reform law of 2010. We have anopportunity to change health outcomes andthe health care system so that they benefiteveryone.

The United States faces a profound chal-lenge and an unprecedented opportunity. Thisreport examines some of the salient problemswith the health of the American public andour health care system. It describes the oppor-tunities for foundations to work in communi-

ties and improve health outcomes; nationally,funders have an opportunity to be part ofefforts to reform and improve the health caresystem. It posits that the values and principlespresented by the National Committee forResponsive Philanthropy (NCRP) in Criteriafor Philanthropy at Its Best: Benchmarks toAssess and Enhance Grantmaker Impactprovide a guide for health foundations andother funders to maximize their impact asthey address disparate health outcomes andbegin implementing reform of the healthcare system.

Against the background of overall valuesthat serve the public good and support civicengagement as part of a participatory democ-racy, NCRP’s benchmarks give specific guid-ance for effective grantmaking. In 2009,NCRP challenged grantmakers to provide atleast 50 percent of their grant dollars to ben-efit marginalized communities and to provideat least 25 percent of their grant dollars for“advocacy, organizing and civic engagementto promote equity, opportunity and justice.”Intentionally prioritizing those communitiesthat are persistently underserved within oursociety can produce lasting benefits foreveryone in the country. Such targeted grant-making includes the collective empowermentof people through the support of communityorganizing and advocacy.

New analyses of health grantmaking datasuggest that of 880 sampled foundations, 31percent devoted at least half of grant dollarsto marginalized communities and 4 percentclassified at least a quarter of health grantdollars for systemic change and social jus-tice, a proxy for advocacy, organizing andcivic engagement. If health grantmakingcomprises more than $1 million annually fora foundation, that foundation is slightly morelikely to meet both benchmarks.

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Towards Transformative Change in Health Care

1

This report contends that grantmakers inhealth will have the most success in improv-ing health outcomes and achieving broaderreform if they focus a great deal of attentionand funding on marginalized groups and ifthey do so by addressing systemic inequality.The report posits health outcomes and healthcare reform as inextricably intertwined. Itmoves from a discussion of the health out-comes of people in the context of their com-munities to the structural challenges andopportunities presented by the health reformlaw of 2010, including the unprecedentedemphasis on public health and improving thepublic health system. This brings the argu-ment back full circle to the community leveland issues of justice. This broad view is meantto encourage foundations and funders of vari-ous types to consider addressing the underly-

ing economic and social inequities that ham-per the performance of the health care systemand that diminish us morally as a nation.

Using positive examples, this report pres-ents the many forward-thinking projects, pro-grams and long-term emphases that grant-makers have undertaken to address bothhealth outcomes and health policy. They aretruly exemplary. For those foundationsdesigning programs and setting strategies forthe next few years, this aspirational workdeserves scrutiny and replication.

Although the civic sector makes progressevery day, the philanthropic field and ournation cannot afford – economically, politicalor morally – to step backwards. Now is thetime for more philanthropic leaders to stepforward and support the movement towardhealth equity.

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NATIONAL COMMITTEE FOR RESPONSIVE PHILANTHROPY

I. Introduction

Health outcomes and health care in theUnited States correlate negatively with theirorigin in a country of vast power, wealth andopportunity. Chronic disease is a leadingindicator of the country’s failure to ensuregood health outcomes and to provide anaccessible, affordable and efficient healthcare system. Diseases such as diabetes, con-gestive heart failure, untreated depression,coronary artery disease and asthma are moreprevalent in lower-income communities,communities of color and other historicallydisadvantaged groups that are affected dis-proportionately by persistent inequities. Butthey also strike into the general population sodeeply that they account for well over 70percent of overall health care costs.1 SusanDentzer, the editor-in-chief of Health Affairs,stated, “As in many things in health care andhealth spending, American ‘exceptionalism’is the rule: The United States is doing anespecially rotten job of delivering chroniccare, at spectacular costs.”2

In 2009, the U.S. spent 17.6 percent of itsgross domestic product (GDP) on health care,more than any other industrialized country.Further, U.S. health inequities cost the nationbillions of dollars each year in direct expen-ditures for the provision of care to sicker andmore disadvantaged populations. When lostproductivity, wages, absenteeism, familyleave and premature death are factored in,the costs rise into the trillions.3 Grantmakerscharged with addressing health outcomesand health care currently have opportunitiesto work in communities to improve healthand to work across the nation to implementthe health care reform law of 2010.

In 2009, the National Committee forResponsive Philanthropy (NCRP) challengedthe philanthropic sector to employ principlesto function “at its best.”4 As articulated in its

publication Criteria for Philanthropy at ItsBest: Benchmarks to Assess and EnhanceGrantmaker Impact, two of the metrics thatfocus on values call for grantmakers to servethe public good by contributing to a strong,participatory democracy that engages allcommunities. Specifically, it urges grantmak-ers to provide at least 50 percent of their grantdollars to benefit lower-income communities,communities of color and other marginalizedgroups. It also calls on them to provide atleast 25 percent of their grant dollars foradvocacy, organizing and civic engagement topromote equity, opportunity and justice.

In addition, NCRP identifies guiding prin-ciples that inform grantmaking that is trans-formational. First among the principles is theuse of systems theory, which focuses on howcomplex structures work in relationship toeach other. Inherent in systems theory andsystems thinking is an appreciation for thekind of causation that is not linear but ratheris reciprocal, mutual and cumulative.

To measure overall well-being, NCRP rec-ommends using the American HumanDevelopment Index (AHDI), a compositemetric comprising longevity, knowledgemeasured by access to education, and stan-dard of living measured by median personalearnings. These measures can inform policiesso that everyone has an equal opportunity toparticipate fully in society.

A guiding principle puts a priority on mar-ginalized communities, including but notlimited to economically disadvantaged peo-ple, racial or ethnic minorities, women andgirls, people with AIDS, people with disabili-ties, the elderly, immigrants and refugees,victims of crime or abuse, offenders and ex-offenders, single parents and lesbian, gay bi-sexual, transgender and questioning (LGBTQ)citizens. Related to this emphasis is the prin-

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ciple of employing “targeted universalism,”which holds that programs designed to targetmarginalized communities also benefit thebroader population. Even elites suffer if anypopulation within the country is marginal-ized or excluded because the impact is onthe United States’ ability to participate fullyin the interconnected global context in whichwe now live.5

Targeted universalism also posits that eachindividual’s particular circumstances, regard-less of elite or marginal status, define a par-ticular context for her or him. In short, thehealth of all individuals is influenced by theirspecific circumstances, an issue for whichuniversal programs fail to account.

Finally, NCRP recommends funding signif-icantly many levels of advocacy and policyengagement that are critical factors not onlyin improving the health of communities butalso in helping to direct the largest invest-ment of public resources in decades throughhealth reform.

NCRP’s values and principles make partic-ular sense at this time for health philanthro-py. Health outcomes and health care involvecomplex structures requiring systems thinkingto improve them and make them cost effi-cient. Improving the health of people in com-munities necessitates social inclusion andexpanding the definition of health to becomemindful of the multiple dimensions of well-

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GRAPH 1: Distribution of Grantsfrom Foundations who Gave in 2007–2009, by Subject Area

SUBJECT AMOUNTA. Education $4,028,723,499B. Health $2,600,230,673C. Human Services $2,379,178,602D. Arts and Culture $2,010,069,596E. Public Affairs/Society Benefit $1,848,398,298F. Environment and Animals $930,761,990G. Science and Technology $499,290,232H. Religion $295,945,689I. Social Sciences $117,647,997J. Other $11,531,254K. Unspecified $38,333L. International Affairs, Development,

Peace, and Human Rights $14,816

*These amounts are too small to appear in the graph.

**

*

A. 27%

B. 18%

C. 16%D. 14%

E. 13%

F. 6%

I. 1%H. 2%G. 3%

GRAPH 2: Distribution of HealthGrants from Foundations who Gave in 2007–2009

HEALTH SUBJECT AREA AMOUNTA. Hospitals and Medical Care $872,413,466B. Medical Research $521,855,691C. Public Health $354,526,977D. Specific Disease $264,508,500E. Other $198,024,714F. Mental Health $185,327,813G. Reproductive Health Care $113,399,109H. Policy, Management,

and Information $90,174,403

Source: Foundation Center

A. 34%G. 4%

C. 14%

D. 10%

B. 20%

F. 7%

E. 8%

H. 3%

being of people in communities. Targetingunderserved communities and finding solu-tions for them would alleviate the moral andeconomic burden of health inequities anddisparities in health care.

The combination of tough economictimes, deplorable health outcomes and theinefficient health care system calls for phi-lanthropy writ large – that is, more thanhealth funders – to work for equity inhealth outcomes and health care through-out society. To funders that want to make adifference in the well-being of all of theirneighbors, NCRP’s principles provide a per-suasive guide for their work.

Applying NCRP’s principles of Philanthropyat Its Best to health funding makes sensebecause doing so helps to promote the com-mon good, an enduring philanthropic andAmerican ideal. Close to a half century ago, in1965, John Gardner, a Republican and secre-tary of health, education and welfare forDemocratic President Lyndon B. Johnson,spoke to the president’s cabinet about thechallenges of implementing the Great Societyprograms. Gardner told them, “What we havebefore us are some breathtaking opportunities,disguised as insoluble problems.”6

The United States has a historic opportuni-ty for transformative change in two places: inour communities and in the health care sys-tem that operates in those communities. Thetransformation must hold a laser-like focus onequity. Dr. Don Berwick, administrator of theCenters for Medicare and Medicaid Services,contends that America’s largest health andhealth care issue is equity.7

This report approaches the issues ofhealth outcomes and health care in two sec-tions. First, it presents a view of health out-comes within the context of people’s lives,including factors such as place, race andwealth. Second, it focuses on the health caresystem and the opportunity presented by theimplementation of the Patient Protection andAffordable Care Act to improve that system.The primary audience for this report com-prises health funders but the strategies andoutcomes presented here also apply to fun-ders working on other issues.

NCRP believes that use of its values andaspirational benchmarks can enhance phil-anthropic work and increase its impact.Therefore, throughout both sections, thevalues and principles of NCRP are reflectedin the positive examples of work takingplace in communities to improve healthoutcomes and in the nation to improve thehealth care system.

The report states without reservation thatthe NCRP principles provide a guide to thoseinterested in practicing transformative philan-thropy through improving health and healthcare for all Americans. The report does notcover international health grantmaking, afield too large for the already broad scope ofthis report.

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DIAGRAM 1: Newtonian Perspective Vs. Systems Thinking

SYSTEMS THINKING

Causation is reciprocal,mutual, and cumulative.

THE NEWTONIANPERSPECTIVE

Social phenomena may be understood by breaking down the sum of the constituent parts.

Source: Criteria for Philanthropy at Its Best: Benchmarks toAssess and Enhance Grantmaker Impact, March 2009.

Imagine two communities in the midwesternUnited States. If you grow up in one, youcan reasonably expect to live approximately88 years or more. But if you grow up in theother, less than nine miles away, you canexpect to live approximately 64 years. Youwould not think an 18-minute drive couldtake 24 years, but that is the very real differ-ence in life expectancy between someonewho grows up in Lyndhurst, a suburb ofCleveland, and someone who grows up inHough, a neighborhood in the inner city ofCleveland.8

Unfortunately, inequities like these per-sist across communities throughout thecountry even today. Health outcomes clear-ly mirror the social determinants of health –the public health framework incorporatingsocial and economic factors in the under-standing of the health of people and ofcommunities. The simple truth is, your zipcode is predictive of your health and yourlongevity more than any factor known. As aresult, inequities are starkly magnified at thecommunity-level and it is here that thehealth care system succeeds or fails.

Dr. Anthony Iton of The CaliforniaEndowment has challenged his colleaguesto look into the eyes of the children toassess the health of a community. The kindof pattern recognition that a skilled clini-cian uses to assess and begin to diagnose aperson’s psychological and physical condi-tion by looking at them has been imitatedin recent years through research that diag-noses the health status of communities.9

Such research has resulted in an under-standing of the role of place in the healthoutcomes of Americans.

“Systemic, avoidable, unfair and unjust”are Dr. Iton’s words for the inequities thatresult from “socio-ecological” factors, includ-

ing discrimination, institutional power andneighborhood conditions. These social deter-minants of health play a larger part in healthoutcomes than do risk behaviors, disease orinjury, or mortality, which comprise the usualmeasures of the “medical model” that hasdominated the country’s public health andmedical care. The medical model fails to seepeople in context.10

Context helps us understand the rootcauses of health outcomes. For instance,social “stressors” have biochemical effects.The body releases cortisol in response tostress.11 Higher levels of cortisol are correlat-ed with lower life expectancy. Take away thenegative stressors in people’s communities –poor housing, the inability to read, discrimi-nation, powerlessness, violence and poverty– and you improve health outcomes.12

While traditional medical care is criticaland must be reformed, it can no longer beour sole focus. Dr. David Satcher, former U.S.surgeon general, notes that between 1991and 2000, advances in medical technologyaverted 177,000 deaths, but he also notesthat the elimination of disparities betweenAfrican Americans and whites could haveaverted 886,000 deaths. He contends, “If wecan achieve health equity and create healthycommunities, we can do more to improvethe overall health of the nation than is likelyfrom advances in medicine.”13

RACE AND WEALTH One of the most salient differentiating factorsin American life is race. California Newsreel’svideo “Race – the Power of an Illusion,”made for the Public Broadcasting Service in2003, explains that race is a “biologicalmyth” with no genetic basis. In American his-tory, this myth gave rise to policies and judi-


II. Communities: People in Context

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cial decisions that were overtly racist.14

Policies that worked to the advantage ofwhites were so pervasive and long-lived thatwhites came to accept the benefits of suchpolicies as evidence of their often unspokenracial superiority. Those policies continue toinfluence life opportunities:

“Today, the average black family hasonly one-eighth the net worth or assets ofthe average white family. That difference… is not explained by other factors, likeeducation, earnings rates, savings rates. Itis really the legacy of racial inequalityfrom generations past. No other measurecaptures the legacy, the sort of cumulativedisadvantage of race, or cumulativeadvantage of race for whites, than networth or wealth.”15

Between 1984 and 2007, the gap betweenthe assets of white families, not includinghome equity, versus African American fami-lies increased fivefold.16 Include home equityand the gap becomes even greater. Even ana-lyzing income alone, in no states do AfricanAmericans, Latinos or Native Americans earnmore than Asian Americans or whites.17

Specifically, for every dollar owned by themedian white family in the United States, thetypical Latino family has twelve cents and thetypical African American family has a dime.18

Place, race and wealth are intermingledand interdependent. The National Committeefor Responsive Philanthropy (NCRP) encour-ages funders to employ several guiding prin-ciples as they approach society’s complexproblems. In this case, systems thinkingexplains how place, race and wealth areinterwoven into the health of communitiesand therefore cannot be analyzed in isola-tion. Rather, their effects are mutual andcumulative.

The Measure of America, Mapping Risksand Resilience, published in November 2010,contains a data-driven argument using theAmerican Human Development Index(AHDI) for “increasing resilience in health”from the standpoints of social determinantsand health care reform.19

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Source: HD Index and Supplemental Indicators by State, 2010-2011 Dataset, American Human Development Project, SocialScience Research Council20

GRAPH 3: Social Determinants of Health

Gender Matters

Race Matters

Place Matters

It All Matters

Women

Men

Asian American

Latino

White

Native American

African American

A Native American in California

A Native American in South Dakota

An Asian AmericanWoman in Connecticut

A Native American Man in Oklahoma

Life Expectancy (Years)60 80 100

EXEMPLARY FOUNDATIONS EMPLOYING A CONTEXTUAL LENS IN HEALTH GRANTMAKINGSome foundations have played a critical rolein creating an inclusive view of people intheir contexts. The W.K. Kellogg Foundationsupported the “Place Matters” initiativethrough the Joint Center for Political andEconomic Studies that worked with 21 coun-ties and three cities to establish community-based leadership focusing on specific socialconditions related to health.21 One site wasAlameda County, Calif., part of the Bay AreaRegional Health Inequities Initiative (BARHII),a regional collaboration of public healthdirectors, health officers, senior managersand staff from ten counties and the City ofBerkeley. Data from this work show that lifeexpectancy in the Bay Area conforms to a“social gradient”: the more wealth andincome people have, the longer they live.Within the ten participating counties ofBARHII, people living with the least povertycan expect to live ten years longer than thoseliving with the most poverty. These findingsaffirm the insight that “Social Policy is HealthPolicy, Economic Policy is Health Policy,Education Policy is Health Policy.”22

This understanding is reflected in TheCalifornia Endowment’s Building HealthyCommunities strategy. This prevention-basedapproach fosters environments where childrenare healthy, safe and ready to learn in 14 com-munities where “the need is great, but thepotential for transformation is even greater.”Choosing priorities and selecting strategies arein the hands of community residents who forma “hub” through which they work together onhow to improve conditions for families andchildren. The ten-year investment will providelong-term support to communities to make asustainable difference in public health.23

Smaller foundations also lead such place-based work in their communities. The HealthTrust, a private foundation working in SiliconValley (see Spotlight) and the New Hampshire-based Endowment for Health, a statewide pri-vate foundation, are examples of local and statefoundations that are changing the socio-ecolog-ical systems in their respective environments.

The Endowment for Health has chosen astwo of its four priorities, or themes, for itswork: Economic Barriers, and Social andCultural Barriers. Taking a broad view ofhealth, the foundation explains, good health isa product of where and how we live and work,our access to care, our individual and collec-tive behavior, and our family and communityhistory. In this mix, economic status has a fargreater impact on health than our egalitariansociety would like to admit. Economic barriersto health include lack of access to care, safehousing, healthy food and physical activity.24

The foundation’s Social and CulturalBarriers theme hones in on rigorous data col-lection to document disparities andinequities, best practices for culturally appro-priate care, diversification of the health work-force and empowerment of vulnerable popu-lations to self-advocate.

The Endowment for Health, The HealthTrust and The California Endowment reflectNCRP’s principles for exemplary philanthro-py: using systems thinking, they documentthe social determinants of health within com-munities; they place an intentional priorityon disadvantaged communities and theyenable the empowerment of the people inmarginalized communities. They supportcommunity organizing and advocacy, and,finally, both explicitly and implicitly, theyencourage greater civic engagement.

In North Carolina, collaboration betweenthe Duke Endowment and Duke UniversityMedical Center has advanced prevention andequity. The Medical Center was experiencinguncontrolled costs as a provider of care inDurham County’s safety net. It was spendingan estimated $45 million in yearly patientcare costs for individuals who were unable topay. In response, it started an experiment incommunity health seven years ago to reducechronic illnesses among the uninsured aswell as to reduce mounting costs of emer-gency room visits. It formed a partnershipwith the Lincoln Community Health Centerto expand primary health services and makethe community healthier through a yearlycontribution of $7.5 million towards support-ing primary care. The Duke Endowment

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stepped in with critical early money toenlarge and equip the first clinic to open. Todate, the partnership has created three clinicsto complement the county’s safety net, whichtreats patients who are 80 percent uninsuredand 50 percent African American. In addi-tion, the Medical Center also listened toadministrators and teachers at a local highschool who explained that students withchronic illnesses could not learn. Theresponse was to staff and subsidize a school-based health clinic that now sees 1,750patients per year and includes a full-servicepharmacy. Significantly, Duke MedicalCenter’s outreach and support have improved

its relations with African American andLatino community members.25

The Duke Medical Center and the DukeEndowment identified inequities resultingfrom the way that complex structures andrelationships in their community intersect:the role of the Medical Center in the safetynet, the need for expanded community-basedprimary care, the need to target chronic dis-eases among high school students and theneed to focus on marginalized communities.They made alterations to the delivery ofhealth care taking those factors into theirplanning and execution of a more efficientand cost-effective safety net system.

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Spotlight: The Health Trust

The Health Trust, a private foundation working in Silicon Valley, is changing the “socio-ecologi-cal” context of health care by emphasizing six values – respect, integrity, innovation, collabora-tion, diversity and stewardship. It works through three initiatives: Healthy Living focuses onincreasing access to physical activity and healthy food; Healthy Aging supports nutrition, physi-cal activity and social engagement for older adults and improves systems for their caregivers;and Healthy Communities works to reduce health disparities through programs and policychanges that seek to improve health outcomes.

Demonstrating a deep commitment to addressing disparities and thus making changes thatbenefit everyone in the Healthy Communities, the foundation’s work includes:• Using promotoras (peer educators) to provide readily accessible information to the local

community, as well as providing evidence-based Chronic Disease Self-Management.• Conducting HIV/AIDS prevention presentations in high schools and colleges, and providing

case management services, housing services and nutrition support services to more than 800people with HIV/AIDS.

• Conducting oral health education for families, enrollingchildren in dental insurance, operating the Children’sDental Center and advocating for water fluoridation.

• Raising awareness about health disparities and their rootcauses, including poverty, poor education, lack of afford-able housing and lack of diversity in the health workforce.

• Partnering with and funding the Public Health Departmentto analyze and present data that illuminate healthinequities in Santa Clara County.

• Ensuring access to health insurance and to health care,such as through outreach and enrollment of children andproviding patient navigation services.

More information at: http:/ /www.healthtrust.org/initiatives/communities/ index_com.php.

“Although common parlance often refers tothe U.S. health care ‘system,’ it is anythingbut. It comprises many uncoordinated pieces,lacks a common strategy and seldomachieves the promise of consistently highperformance seen in other sectors of theeconomy,” assert Janet Corrigan and DwightMcNeill of the National Quality Forum.26

The present “system” fails with regard tocoverage: the number of uninsuredAmericans has risen to 50.7 million or 16.7percent of the population, according toCensus Bureau figures released in September2010.27 And it fails with regard to perform-ance. For example, “Thirty nations, includingless affluent countries like Portugal, Sloveniaand Malta, have a lower infant death ratethan Washington State, which has the lowestrate of infant death among U.S. states.”Washington, D.C., has the highest infantmortality rate in the U.S., performing slightly

better than Belarus despite spending 13 timesmore on health care.28 This links directly tothe issue of resource inefficiency: “Americansare paying top dollar for mediocre results.”29

According to the Center for Medicare andMedicaid Services, in 2009 health spendingin the United States accounted for 17.6 per-cent of GDP.30 In 2006, U.S. health spendingas a share of GDP was higher than all othercountries measured by the Organisation forEconomic Co-operation and Development.31

In June 2009, the White House Council ofEconomic Advisers projected that the share ofGDP going to health care would reach 34percent by 2040 if costs continue to grow atthis rate.32 Yet, in 2010, “the residents oftwenty-nine countries live longer lives, onaverage, than Americans do - while spendingas much as eight times less on their health.”33

Any philanthropy concerned aboutaddressing inequities in our current health


III. The Non-System of Health Care

10

GRAPH 4: Health Care Expenditure and Infant Mortality

$10,000

$6,000

$2,000

15

9

3

� Health Expenditures per Person (2008 USD)— Infant death rate, 2006 (per 1,000 live births)

In an analysis of all 50 U.S. states and the

District of Columbia and independent coun-

tries with better infant death rates than at

least the worst-performing U.S. state,

researchers found that the United States

experiences an infant mortality rate nearly

four times higher than Iceland. Iceland has

the lowest infant mortality rate even though

the U.S. spends more than twice what

Iceland does per person on health. The situa-

tion is worse in the nation’s capital, which

spends two-and-a-half times as much as

Iceland and experiences infant mortality rates

nearly seven times higher.

Iceland United StatesDistrict

of Columbia

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care system must acknowledge the socialdeterminants of health when considering itsgrantmaking strategy. Indeed, the recognitionthat the health care sector excluded toomany people and cost too much provided alarge impetus for health care reform.Philanthropic support for community organ-izing, coalition building and advocacy,described in-depth below, helped pave theway for the enactment of reform.

THE PATH TO HEALTH REFORM:COMMUNITY ORGANIZING, COALITIONBUILDING AND ADVOCACYCommunity organizing, coalition buildingand many levels of policy engagement helpedto successfully pass legislation that will beginto tackle the country’s toughest problems withhealth care. Work initiated by organizersfocused on health reform in the early 1990scontinued for almost another two decades,culminating in the formation of Health Carefor America Now (HCAN). Comprising morethan 1,000 member organizations, HCANwas the “deepest single-issue coalition inmodern American history.”34 HCAN workedwith more than 800 local organizations in 44states and with three national organizing net-works, several national unions and nationalorganizations representing women and peo-ple of color to bring about reform.

The Atlantic Philanthropies made thelargest grants among several foundations andunions that provided more than $48 millionfor the effort. Some members of HCAN suchas the Center for Community Change, U.S.Action and the Northwest Federation ofCommunity Organizations also worked withother advocates to advance health reform.Working both with the HCAN coalition andwith advocates throughout the states, theHerndon Alliance researched, proposed andexecuted communications strategies toexplain to the people the need for majorreform of the American health care system.

Advocacy throughout the states formedand grew strong throughout the same years ofthe 1990s through the leadership ofCommunity Catalyst, Families USA, theGeorgetown Center for Children andFamilies, the National Women’s Law Center,U.S. Action, the National Health LawProgram and the Center on Budget andPolicy Priorities and its State Fiscal AnalysisNetwork. In the states, “systems of advocacy”formed, which encouraged coordination ofefforts with policy, organizing, legal and fis-cal expertise.35

For several years, these systems workedon many levels, defending public programsand incremental reforms at the state levelwhile simultaneously advocating for nation-al reform from their state perches. Those

As many as 5,000 people are estimated to have participated in Seattle's March and Rally for Health Care Reform onMay 30, 2009. Photo Credit: Neil Parekh/SEIU Healthcare 775NW.

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SPOTLIGHT: The AffordableCare Act Advocacy FundCollaboration Among SevenNational Foundations

Broad in scope, the Affordable Care Act (ACA) cedes

significant policy discretion to the states, where poli-

cymakers face daunting tasks over the next few years.

As such, the role of state advocacy organizations in

implementing ACA provisions is pivotal. Well-

resourced advocates skilled in public education,

administrative, legislative and legal advocacy, com-

munity organizing and policy analysis will be critical

to ensure successful implementation of health reform.

The Atlantic Philanthropies, The California

Endowment, The Nathan Cummings Foundation, Ford

Foundation, The Jacob and Valeria Langeloth

Foundation, The Rockefeller Foundation and The Wyss

Foundation are the initial collaborators on the nascent

ACA Advocacy Fund. The fund will provide a vehicle

for national, state and local funders to collaborate in

directing strategic grants to systems of advocacy,

which consist of multiple organizations with varied

skills working collaboratively. It also is intended to

increase the overall level of support for state-based

advocacy during health reform implementation.

An advisory committee comprising contributing

funders will work with Community Catalyst, a nation-

al health advocacy organization with extensive expe-

rience in the states. Collaboration on this scale – with

seven national foundations and pooled funds that will

boost the impact of these foundation dollars – is rare

in philanthropy.

years taught advocates about the interactingand cumulative effects of working collabo-ratively on a systems level, skills that arenow essential to ensuring successful imple-mentation of reform. Since the 1990s, thePublic Welfare and The Nathan Cummingsfoundations nurtured state-based consumerhealth advocacy organizations while TheDavid and Lucile Packard Foundation culti-vated state-based children’s advocacyorganizations. The Robert Wood JohnsonFoundation gave this trend strong supportwith its Consumer Voices for Coverage pro-gram working in 18 states.36

All of the aforementioned organizationsemphasized social inclusion and marginal-ized communities, particularly the needs ofracial and ethnically diverse groups, in theirpolicy stances and their organizing work. TheJoint Center for Political and EconomicStudies (JCPES), the National Council of LaRaza (NCLR) and the National Associationfor the Advancement of Colored People(NAACP) worked to keep the issue of racialand ethnic equity in the debate and analyzedoriginal research and data on the human andfinancial costs of health inequities. Theemphasis of the health reform law onaddressing racial and ethnic disparities inhealth and health care builds on these orga-nizations’ prior work on equity.37

The strategies and skills developed in themany years leading up to passage of thePatient Protection and Affordable Care Act(PPACA, commonly referred to as theAffordable Care Act or ACA) provide a solidbasis for the coming years of implementation.Grantmakers have access to an extensivecadre of experienced organizers, policyexperts and advocates on the national, stateand local levels to boost their impact andcreate sustainable long-term change.

There is growing momentum towardincreased collaboration among foundationsand national advocacy and policy organiza-tions. Some who worked for reform shiftedquickly to its implementation while otherschose to wait and have now started to leadimplementation at the state and local levels,where it will count most.

The focus on addressing health in the contextof people’s lives in communities blends wellwith the pressing need for reforming thehealth system through the full implementa-tion of the ACA. The Measure of Americaarticulates this need:

“Variations in access to and quality ofhealth care account for about 10 percentof the life expectancy gaps observed in theUnited States overall … And universal

health coverage is vital both to savinglives and to addressing the leading causeof bankruptcy among U.S. households:medical bills. Health insurance con-tributes to both health security and eco-nomic security, essential foundations of afreely chosen life of value.”38

The states will have major influence onthe implementation of the federal law. Localofficials understand on a daily basis the

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IV. The Affordable Care Act

SPOTLIGHT: Patient Protection and Affordable Care Act – Summary of key provisions39

Signed into law in 2010 by President Barack Obama, the Patient Protection and Affordable Care Act(PPACA) is among the country’s most transformative social policies in decades. Below is a summary of keyprovisions for funders to keep in mind as the law is implemented.

Insurance Coverage Expanded• Insurance market reforms eliminate discriminatory practices and cap insurance company administrative

expenses.• Its mandate requires individuals to maintain minimum essential coverage and requires employers with 50

or more employees to offer coverage.• Refundable tax credits are instated to ensure affordability of insurance.

American Health Benefits Exchanges Established by the States• Qualified health plan offering essential benefits with cost sharing limits.• Quality accreditation for all plans; standardized presentation of benefits.• State-level flexibility to establish basic health plans for lower-income individuals and to form compacts

with other states for cross-state sale of health insurance.

Public Programs• Medicaid expansion – by 2014, to all children, parents and childless adults with family incomes up to

133 percent of the federal poverty level; 100 percent federal financing for the newly eligible from2014–2016; Community First Choice Option through Medicaid for community-based attendant servicesand support for beneficiaries with disabilities.

• Children’s Health Insurance Program – income eligibility levels maintained through September 30, 2019.States receive an increase in the federal matching rate starting in 2014 through 2019.

• Simplified Enrollment – state-run websites established and enrollment among Medicaid, Children’sHealth Insurance Programs and exchanges coordinated. (continued on page 14)

Improving Quality and Efficiency• National strategy to improve service delivery, outcomes and population health.• Center for Medicare and Medicaid Innovation for payment and delivery models.• Increased provider fees, protections for hospitals and bonus payments for emergency services in rural areas.• Restructures Medicare Advantage payments according to fee-for-services rates. Discounts available for

drugs during the coverage gap, with plans for gradual elimination of the gap.

Prevention of Chronic Disease and Improving Public Health• Establishes a Prevention and Public Health Investment Fund and a national prevention strategy.• Develops healthy communities and a 21st century public health infrastructure.• Supports school-based health centers, establishes an oral health prevention education campaign, and

provides 100 percent Medicare coverage for prevention and incentives for Medicaid preventive services. • Funds for research in prevention and public health practices, including collecting data by race, ethnicity

and primary language.

Workforce• Improves loan programs and repayment requirements to support the workforce, particularly in medically

underserved areas and populations.• Supports training programs for primary care physicians and ancillary personnel and for training in team-

based approaches.• Expands funding for federally qualified health centers and co-location of primary and specialty care in

community-based mental and behavioral health settings.

Transparency and Program Integrity• Establishes Patient-Centered Outcomes Research Institute.• Enacts Elder Justice Act to eliminate abuse, neglect and exploitation of the elderly.

Long-term Care• Establishes Community Living Assistance Services and Supports (CLASS), a national voluntary self-funded

long-term care insurance program.


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enormous pressure being created by poorhealth and high costs. As Alan Weil of theNational Academy for State Health Policystates, “I have yet to meet a governor whohas said, ‘I’m going to intentionally do a badjob at this to make another level of govern-ment look bad’ … They’re accountable to thepeople, and the voters are too smart to letsomeone get away with that.”40 This is espe-cially true if systems of advocacy on thenational and state levels adroitly monitorand publicize the state-level decisions.Building local policy engagement and advo-cacy capacity is among the many criticalways that foundations can help ensure effec-tive implementation.

President Barack Obama’s signature on the health care reform bill at the White House, March 23, 2010. Official White House Photo byChuck Kennedy.

SPOTLIGHT: Resources forFederal Health ReformImplementation in Kansas —A Collaboration among FiveState Foundations

Five Kansas-based health philanthropies – the HealthCare Foundation of Greater Kansas City, Kansas HealthFoundation, REACH Healthcare Foundation, SunflowerFoundation and the United Methodist Health MinistryFund – are pooling funds in support of efforts to ensureoptimal implementation of the Affordable Care Act inKansas. Grants ranging from a minimum of $5,000 to amaximum of $30,000 will go to state agencies and col-laboratives of those agencies, consortiums of organiza-tions doing regional work, nonprofit organizations andlocal governmental entities. Funds will support the sub-mission of grant requests; legal, actuarial or policydevelopment for state agencies; stakeholder engage-ment in implementation processes; participation inconferences and public education.

The philanthropies are working with the KansasHealth Consumer Coalition (KHCC) to secure healthconsumer engagement in the formulation and imple-mentation of appropriate grant projects. These grant-makers also are partnering with the KansasAssociation for Local Health Departments on techni-cal assistance efforts. In addition, the fund will hire agrant coordinator to publicize the program, encourageresponses to ACA opportunities, coordinate grantreview, issue awards and process reports. The coordi-nator will work closely with KHCC, the KansasMedicaid Agency, Kansas Insurance Department andother public health and research organizations.

Billie Hall, CEO of the Sunflower Foundation,explained the collaborators’ rationale: “We have anobligation to make sure consumer groups are at theright place at the right time during this implementa-tion process. This is an opportunity for funders towork with coalitions in the state and to ensure betterconnections with stakeholders.”

Now that health reform has been enacted into law,funders are encouraging communities to participatein adopting practical steps and developing solutionsto improve the health of all Kansans.

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The joint federal-state model complicatesACA’s implementation and the long period offour or more years for implementation opensit to challenges. The widespread realization,however, is that the status quo cannot pre-vail, lest the U.S. seriously jeopardize its eco-nomic future.41 Avoiding that outcome is anincentive for U.S. society and health grant-makers to help communities identify the rootcauses of bad health outcomes while reform-ing the health care system to improve thecare of each patient, to improve the health ofthe entire population and to lower costs.

Many national advocacy organizations andfoundations have provided the public withimportant descriptions, analyses and discus-sions about the challenges of implementing var-ious elements of the ACA. Both major andminor provisions of the law afford opportunitiesto employ principles of exemplary grantmakingto increase impact and long-term sustainability.

EXPANSION OF COVERAGE TO LOWER-INCOME PEOPLE The ACA codifies specific health insurancereforms and the requirement for everyone tohave insurance, two important changes thatwill spread risk and costs across the populationmore equitably. Two major features of reformare the availability of insurance coverage withsubsidies based on income through state-basedinsurance marketplaces called “exchanges”and a major expansion of Medicaid coveragefor all lower-income people. The ACA alsofocuses on prevention, chronic diseases, com-munity health and health equity for the coun-try’s diverse population.

The Medicaid expansion to millions ofuninsured Americans will reach into some ofthe nation’s deepest pockets of poverty andneglect, with the southern states standing tobenefit the most from the largest expansions.42

Marginalized populations including the work-ing poor and racial and ethnic minorities willreceive defined benefits. Grantmakers canfocus on the Medicaid population to comple-ment the role of state governments in manyways. Using a targeted approach, they canreach out to and enroll eligible citizens,

improve access to primary and specialty care,foster community-based options for long-termcare and use payment policies to contain costsand improve quality. The Center for HealthCare Strategies (www.chcs.org) and theNational Academy for State Health Policy(www.nashp.org) are assisting nonprofits andlocal government in the states to make thispublic program for vulnerable populations intoan example of high performance.

Experienced advocates on the state levelnot only help to expand the reach ofMedicaid, but also to maintain and improveits quality. Nonprofit advocates will workclosely with the new Consumer AssistancePrograms established by ACA through federalgrants to state entities.43 The independentstate and nonprofit efforts will serve a “sen-tinel function” by working “closely with gov-ernment officials to alert them to emergingtrends, issues and challenges faced by theirshared constituencies.”44

INSURANCE EXCHANGESState-based exchanges will provide a market-place for consumers to find affordable andcomprehensive insurance coverage. Throughthe exchanges, lower-income consumers willbe eligible for subsidies through income-basedtax credits. States have substantial leeway toestablish exchanges ranging from those thatmay offer options for comprehensive coverageand affordability to those that offer minimumbenefits. Three of NCRP’s tactics for strategicgrantmaking spelled out in its report Criteriafor Philanthropy at Its Best can help to ensurethat exchanges work in the public’s interest:support for community organizing, increasedcivic engagement of consumers to demandsound policies at the state and national levels,and state-based advocacy.

State-based systems of advocacy (inter-reliant organizations that bring various skillsets to the advocacy system) grew in recentyears with the support of national and localfoundations. The systems combine communityorganizing by multi-issue and faith-basedorganizations with a strong component ofcivic engagement in local and national poli-tics. Some of the same systems have policyand legal experts who can, for instance, pin-point the vast difference between an exchangethat is well-regulated and operates in con-sumers’ interest and one that simply lists poli-cies in the insurance industry’s interest.

The capacities in state-based consumeradvocacy organizations with regard to privateinsurance, however, are uneven across thestates. Some of the organizations located inpolitical environments opposed to reform arethose that need the most support. Foundationassistance to help them cultivate this expert-ise is a current and future need.

The federal Office of Consumer Informationand Insurance Oversight in the U.S.Department of Health and Human Serviceswelcomes strong engagement from consumers.Its deputy director for consumer support, KarenPollitz, and her staff are working for strongconsumer ombudsman programs, responsiveappeals systems, transparency and disclosure:“We cannot run health reform implementationon the honor system … Accountability in

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Protesters during a health care reform rally in Washington, D.C., June 25, 2009. Photo by Syreeta McFadden.

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health insurance is vital. We need consumeradvocates to help make that work.”45

The National Association of InsuranceCommissioners (NAIC) also responds to theconsumer voice. The industry’s lobbyists tothe NAIC number more than 1,000, whereasthere are only about 20 funded consumer rep-resentatives.46 Because insurance is regulatedin the states, it is crucial to build and fostercommunication between national and stateadvocates and to keep up the pressure forestablishing consumer-oriented exchanges.

DELIVERY SYSTEM REFORMDelivery system reform is a critical compo-nent to increase value in the health care sec-tor, as it holds great promise for equity andcontrolling costs. The traditional model offragmented service made worse by a systemof fee-for-service payment that creates morefragmentation serves no one well, especiallythose most in need. Every community canbegin to move toward medical homes orhealth homes that provide primary care andcoordinate specialty care. In the Gulf region,national and local foundation collaborationhas revamped the delivery of primary care in

a way that could be replicated by other com-munities with added support from the ACA.

Efforts such as convening stakeholders andadvocates in communities to address chroniccare, to provide culturally and linguisticallycompetent care and to advocate for commu-nity benefits are given new support throughthe ACA. Foundations have an opportunity toensure that communities play a central rolein leading and monitoring this work

Comprehensive and cost-effective carecan be achieved even for the sickest andpoorest patients. In Boston, with the help ofthe Open Society Institute,48 Dr. RobertMaster formed the Commonwealth CareAlliance, a cost-effective model for the deliv-ery of care to people eligible for bothMedicaid and Medicare. Among the sickestof patients, these “dual eligibles” account for18 percent of Medicaid patients but 46 per-cent of Medicaid expenditures.49

In addition, the Campaign for Better Care,funded by the Atlantic Philanthropies andexecuted by the National Partnership forWomen and Families in conjunction withCommunity Catalyst and the National HealthLaw Program, is addressing the same popula-tion of people who are eligible for both

SPOTLIGHT: Measuring Impact to Support Effective Advocacy— Collaboration Around Primary Care in the Gulf Coast47

National foundations, a local funder and the federal and state governments’ Medicaid program joinedtogether in the Gulf Coast region to expand, stabilize and improve the primary care safety net. TheLouisiana Public Health Institute managed the Primary Care Stabilization Grant from Medicaid, which sup-ported a team-based model for delivering health care services. A personal primary care physician leadseach team, which follows patients and cuts down on the use of emergency rooms. The federal and stategovernments funded local groups and tied grant money to service delivery results. The groups increasedtheir capacity to collect and analyze data about their impact.

The Commonwealth Fund supported the formation of an expert panel on payment, evaluation and qualityimprovement and made a grant to evaluate the work. The Robert Wood Johnson Foundation made a grant totrain primary health care providers in the new systems and procedures. The local funder, Baptist CommunityMinistries, contributed $300,000 for an outreach campaign to advertise the new sites and services.

The results have been dramatic. “We now have 40 certified patient-centered medical homes – more thanany other area in the country,” says Clayton Williams [formerly of the Louisiana Public Health Institute].“The expansion, stabilization and improvement of the primary care safety net have not been done at thislevel in any other state.”

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SPOTLIGHT: Integrated Care and Consumer Involvement— The Commonwealth Care AllianceThe Commonwealth Care Alliance (CCA) is organized as a “consumer-governed care system” to ensure thatthe empowered consumer voice is built into all its activities. Community Catalyst, Health Care for All andthe Boston Center for Independent Living were the founding partners of this service delivery model.

The alliance works to improve health outcomes for people of all ages with special health care needs,whose care is complicated and often very costly. Dr. Robert J. Master developed the model in 2003, with atwo-year fellowship from the Open Society Institute.

CCA’s target population includes people with complex needs covered under Medicaid and those “duallyeligible” for Medicaid and Medicare, including adults 65 and older, and individuals with serious physical,cognitive or chronic mental illness.

CCA’s team-based approach to care embodies several principles from systems theory critical to improvingcare and managing costs. These include care management by the primary care clinician along with nurse practi-tioners, nurses and behavioral health practitioners; care coordination by the primary care team to optimize themanagement of medical and psychosocial issues and promote stability; 24/7 access to care providers; clinicalinformation systems to support the entire network and promotion of enrollee participation in care planning.

CCA data show that:• Care of severely physically disabled Medicaid patients

under the pre-paid, capitated model cost more than$1,000 less per member per month compared toMedicaid fee-for-service.

• The team approach shifted care out of hospitals. • The overall cost of the intervention was $86 per mem-

ber per month.

With advocacy, consumer involvement and integratedhealth and payment system design, CCA demonstrates thatthe care of even the costliest and most complicated patientscan be managed in an efficient and cost-effective way.

More information at http:/ /www.commonwealthcare.org/mcaid_files/ frame.html.

Medicare and Medicaid. The campaign isinvolving patients, their caregivers and con-sumer advocates in identifying models ofcoordinated care for people with multiplechronic conditions. Models of payment sys-tem reform accompany coordinated care tomake care delivery cost-effective. Referring tothose patients most in need, the campaignarticulates the principle of targeted universal-ism in its own words: “If we can make ourhealth system work for them, we can make itwork for everyone.”50

WORKFORCEDevelopment of a workforce to deliver pri-mary care, particularly to marginalized popu-lations, also gets a boost from the ACAthrough support for graduate medical educa-tion for primary care providers, communityhealth workers and navigators trained to helppatients get what they need. The law alsosupports increased racial and ethnic diversityin the workforce. In addition, communitiesare identifying a need for advocacy and statepolicy changes around scope of practice

laws, collaborative practice agreements andreimbursement codes so that clinicians maypractice to their full levels of competenceand receive appropriate compensation.

It is critical to break down the silos ofmedical practice and to train new practi-tioners on every level to work collaborative-ly. For example, in 1996, the city ofAsheville, N.C., improved its employees’health by connecting available resourceswithin the community. The Asheville Projectcombined health education and extendedservices by pharmacists to track patients’compliance with diabetes medication and toprovide interim check-ups. Employees,retirees and dependents with diabetes hadlower blood glucose levels and took fewersick days. The mean insurance cost perpatient per year showed a trend of reductionfrom $6,502 the first year to $2,702 the fifthyear.51 Foundations can support such inno-vations to make maximal use of the existingand future workforce.

With regard to workforce development, theACA includes programs to train lower-incomeindividuals as home care aides and for otherhealth professions as well as support for com-munity health workers. Area health educationcenters will be targeted to underserved popu-lations. Finally, the ACA supports the develop-ment and dissemination of cultural compe-tence training and education curricula, aswell as the establishment of minority healthoffices within key federal agencies.52

Health care for racial and ethnic commu-nities is more effective if delivered by adiverse team of providers:

“Concordance between patient-practi-tioner race/ethnicity has long been recog-nized as a strategy for improving thequality of care. Furthermore, racially andethnically diverse practitioners are morelikely to practice in medically under-served areas and treat patients of colorwho are uninsured or underinsured.Diversity among health researchers isalso critical to pursuing a research agen-da on the elimination of racial/ethnichealth disparities.”53

Some foundations have recognized this andfocus some of their health grantmaking on diver-sifying the health care workforce. The “BuildingHuman Capital” portfolio and the “NewConnections: Increasing Diversity” program ofthe Robert Wood Johnson Foundation work todevelop and retain a diverse, well-trained work-force in health and health care. This funding alsoaims to foster new researchers and scholars fromhistorically underrepresented communities.54

The California Wellness Foundation has taken acomprehensive approach to increasing diversi-ty in the health professions, making morethan $15 million in grants since 2002 toCalifornia nonprofits that increase diversity inthe health workforce. This funding supporteda public education campaign about howdiversity in the state’s workforce improves thehealth of all Californians. The campaign alsoprovides information on health professionopportunities for non-white youth.55

TRANSFORMING PUBLIC HEALTHPerhaps the boldest transformation of theAffordable Care Act concerns the area ofpublic health. There now is a strong emphasison prevention and health promotion, andbuilding an evidence base for both. Therealso is support to build out the public healthinfrastructure, to bolster the role of healthdepartments and to shore up the safety net,which is the medical refuge for those not eli-gible or unable to access health care. TheACA contains mandatory appropriations

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beginning at $500 million in 2010 andincreasing to $2 billion in 2015 and each fis-cal year thereafter for the Prevention andPublic Health Fund.56 More than 90 organi-zations from the public health community,including disease groups, advised:

“Investments in the Fund should beused in a manner that leverages changethroughout the public health systems -with a move away from a stove-piped, dis-ease-by-disease approach to one thataddresses the determinants of health in across-cutting manner … These fundsshould be used for transformational invest-ments, helping lead the nation to a morecommunity-oriented, accountableapproach to public health.”57

Nonetheless, the need for skillful advoca-cy in Washington, D.C., and state capitalswill remain critical to ensure that funds areallocated for community-oriented publichealth. Two state-based foundations havemade funding decisions to improve thehealth of their communities and to supportpublic health. In early 2009, the Kansas-based Sunflower Foundation began to devel-op and support a grassroots campaign for astatewide law to prohibit smoking in publicplaces, which resulted in the Kansas CleanIndoor Air Act only 15 months later. Thecampaign demonstrated that the “public”had to be part of public health, that is, grass-roots advocacy involving the people ofKansas and bringing their voices to decisionmakers was proven to be a critical factor inchanging policy.58

Using its guiding principle of population-based approaches to improve public health, theNorthwest Health Foundation in Oregonemployed the insight that young people weresimultaneously jeopardized by risky behaviorand also were ready for social change. ItsCommunity Health Priorities project helpedyoung people focus on the interconnectednature of ensuring good health outcomes bysponsoring a photo contest and creating a web-site that displays original content around publichealth issues. Two public health professors are

requiring their students to participate in theseweb-based conversations about public health.

The foundation also is leading an assess-ment of community health issues and of thecapacity of the state’s public health system toaddress those issues: “[The assessment]would … help the Oregon Health Authorityarticulate a comprehensive ‘systems’ modelof the key elements of a world-class publichealth system for Oregon that engages a vastrange of stakeholders beyond public healthemployees and county commissioners.” Thefoundation recognizes that both “the engage-ment of youth and the assessment of a world-class public health system are long-termendeavors. They require patience, persistenceand commitment to change.”59

What the ACA adds to such efforts – awell-established and funded public healthinfrastructure with the ballast of federal leg-islative, regulatory and financial support –creates an unprecedented opportunity toattack some of the nation’s most pressinghealth problems, including obesity, diabetesand other chronic diseases. This holds thepromise of constraining medical expendituresby emphasizing population health and pre-ventive measures that can reduce the needfor expensive medical intervention.

Three state foundations in Colorado (Caringfor Colorado Foundation, The Colorado Trustand The Colorado Health Foundation) cat-alyzed a series of steps to extend the state’spublic health capacity by providing start-upfunding for the Colorado School of PublicHealth. In 2006, Governor Bill Ritter conveneda panel to explore health reform options for thestate and the new director of the state healthdepartment set a priority to strengthen thestate’s public health system. The Caring forColorado Foundation then brought togetherlocal and state public officials to examine bar-riers to accessing public health services, toenvision a 21st century public health infra-structure and to implement change. The legisla-ture responded with the Public HealthImprovement Act that mandated the develop-ment and adoption of the state’s first PublicHealth Improvement Plan and the designationof a public health agency in each county.60

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THE TRIPLE AIM: GRANTMAKER-SUPPORTED DELIVERY REFORM TOWARD INTEGRATED CAREA movement is afoot in communities acrossthe nation and in Europe that could helptransform the United States’ health deliverysystem. Dr. Don Berwick articulates this need:

“We have to change the way we deliv-er care in productive and healthy ways topatients. Patients, especially chronically illpatients, are journeying through very com-plex care systems now, and we too oftendrop the ball. Handoffs do not go well,patients get confused, we get confused,systems are not modernized. To me, thehallmarks of the care system that we needare integration, cooperation and seamless-ness. And that means change.”61

The Institute for Healthcare Improvement(IHI) “exists to close the enormous gap betweenthe health care we have and the health care weshould have,” which the Institute of Medicineterms a “quality chasm.”62

In 2007, facing the human and financialcosts and inefficiencies of a siloed health“non-system,” a multidisciplinary team fromIHI created the The Triple Aim initiative. Ithas three primary goals: to improve thehealth of the population, to enhance thepatient’s experience of care and to controlthe per capita costs of care. Though the con-cept initially met with resistance, its inherentsocial and economic soundness took holdand now approximately 60 locales in theU.S. and abroad are official “Triple Aim”sites. Together, they have formed a learningcommunity that benefits from technical assis-tance by experts in process improvement.

Grantmakers have supported and continueto support the Triple Aim and its replication.

In Maryland, the Health Initiative Foundationsupports Montgomery County’s Primary CareCoalition, one of the original Triple Aim sites.

Both the funder and the grantee employprinciples of targeted universalism: thePrimary Care Coalition seeks to improve indi-vidual patient experience, population healthand cost control as it focuses on the county’suninsured population. What benefits the unin-sured population will benefit the general pop-ulation, a primary tenet of targeted universal-ism. What the county learns and institutes forthe uninsured with regard to the coordinationof care, transitions among levels and types ofcare, control of chronic diseases, andimproved lifestyles in the care of 100,000uninsured residents is being designed to ben-efit the practice of health care for all one mil-lion residents of the County.

Collaborating with the effort inMontgomery County, the Regional PrimaryCare Coalition located at the ConsumerHealth Foundation in Washington, D.C., is theTriple Aim initiative’s first site representingand working in an entire region. Foundationsupport of this approach has been integral toits work. The coalition is funded by the

V. Other Opportunities for Reform Across the System

Consumer Health Foundation, The Morris andGwendolyn Cafritz Foundation, Eugene andAgnes E. Meyer Foundation, Northern VirginiaHealth Foundation and Kaiser Permanente ofthe Mid-Atlantic. Similar to other sites, thiswork reflects the Triple Aim vision that “inte-grated care should be textured, locally adapt-ed and under local control.”63

CHRONIC DISEASE AND PUBLIC HEALTH:THE BUSINESS CASEThere are multiple pathways for any healthgrantmaker to allocate its funds; a critical oneis identifying the most effective use of limitedresources. Small investments can producehuge savings. If one looks at the example ofasthma, that disease stands at the intersectionof public health and health care and spansthe age spectrum, affecting both old andyoung. About 23 million people in the U.S.have asthma and it disproportionately strikeslower-income people and racial and ethnicminorities. Among preventable pediatric hos-pitalizations, asthma is responsible for thehighest costs. Direct and indirect costs ofasthma in 2007 totaled $19.7 billion.64

With grantmaker support from The BostonFoundation and the Kresge Foundation, theLowell Center for Sustainable Production at

the University of Massachusetts Lowell and theAsthma Regional Council of New England,located at Health Resources in Action inBoston, developed a business case for asthmaeducation as well as for health insurance forpeople with asthma. Working with the Centersfor Disease Control; the National Heart, Lungand Blood Institute and the Agency forHealthcare Research and Quality (AHRQ),these organizations also developed a set ofbest practices for asthma management. Theseinclude objective measures of lung function,pharmacologic therapy, patient education anda partnership among the patient, his or herfamily, clinicians and employers, and environ-mental control measures to eliminate “asthmatriggers.”65 In this case, multi-year funding bya city-based community foundation, addedfunding by a major national foundation,involvement of the National Business Groupon Health and assistance from federal agen-cies produced a blueprint for improved qualityof life for millions of people and savings in bil-lions of dollars. Proper asthma managementcould prevent $5 billion in costs each year.66

Making such a business case can help founda-tions advocate in their states and communitiesfor holistic, cost-saving care targeted at someof the most disadvantaged people with broadsocial benefits.

Similar to applying a business lens to poli-cy, the use of Health Impact Assessments(HIAs) can improve the efficacy of healthpolicies. The World Health Organization, theEuropean Union and Canada have led thedevelopment of the field of HIAs. A collabo-ration between the Pew Charitable Trusts andRobert Wood Johnson Foundation is support-ing The Health Impact Project to promote theuse of HIAs as a decision-making tool forpolicymakers in the U.S. Health ImpactAssessments:• View health from a broad perspective, tak-

ing into account a wide range of environ-mental factors, such as housing condi-tions, roadway safety and social and eco-nomic variables.

• Consider whether there are subgroupswithin an affected population that may bemore vulnerable to a given impact.

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• Promote civic engagement by engagingcommunity members and other stake-holder groups who will be affected by adecision.

• Present an impartial, science-basedappraisal of the risks, benefits, trade-offsand alternatives involved in the decision.67

HIAs use a structured yet flexible processto help decision-makers advance policies thatavoid unintended consequences and unex-pected costs. Foundations’ support of HIAs,particularly at the state level, encouragesapproaching health from a holistic perspec-tive that is most efficacious for marginalizedpopulations and ensures that policies are costeffective.

THE SAFETY NETThe safety net in most communities compris-es public clinics and hospitals, communityhealth centers, including federally qualifiedhealth centers, “free clinics” and the uncom-pensated care rendered by private sector hos-pitals, clinics and individual providers. Asnumerous as the health care system’s failuresare, they would be magnified but for the for-mal and informal safety net systems.

The ACA provides $12.5 billion for expan-sion of community health centers and place-ment of health professionals in underservedareas. In addition, the expansion of Medicaidwill cover many formerly uninsured patients.However, major reductions in DisproportionateShare Hospital (DSH) funds will start in 2014.DSH payments through Medicaid and Medi -care provide financial assistance to hospitalsserving a large number of low-income patients.Reductions in those payments will curb hos-pitals’ ability to serve people who remainuninsured, estimated to be approximately 23million people.68

These persistently marginalized popula-tions include undocumented immigrants andthose who may be eligible for coverage butrefuse it or lack access to use it. It would bea mistake for foundations and others workingon health equity issues to think that the prob-lem of the safety net will be solved by health

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SPOTLIGHT: StrengtheningMaine’s Safety Net —Grantmakers, Public Sector andCommunity Partnerships YieldTangible Health Improvements

The Maine Health Access Foundation (MeHAF) com-missioned a study, Primary Care Safety NetEnvironmental Scan, and talked with safety netproviders and their patients to identify the key pointsof leverage to bolster Maine’s safety net. Findingsincluded the following needs:• Improving access to and management of medica-

tions through partnerships with care and commu-nity service providers.

• Enhancing medication safety in Maine’s criticalaccess hospitals.

• Preserving Medicaid coverage under federal citi-zenship verification guidelines.

• Improving rural and low-income health careaccess through expansion of federally qualifiedhealth centers.

• Improving rural health care access through tele-health.

• Implementing collaborative strategies to strengthenthe understanding, impact and value of MaineCare(Medicaid) for its members.

For the work to improve rural health and expandfederally qualified health centers, MeHAF invested$160,000 in grants to the Maine Primary CareAssociation and in contracts with an experienced grantwriter to help Maine’s community health centers com-pete for federal grants. In addition, health center staff,board members, community partners and state and fed-eral employees helped with the development of grants.

Of the seven health centers to apply for govern-ment funding, six received federal support and collec-tively receive $2.2 million per year. Among the sixhealth centers receiving MeHAF support, the numberof patients served grew from 35,835 to 65,107 in2007, and an additional 161,880 medical, dental andbehavioral health visits were provided. The centersalso have recruited 15 new physicians, 10 new den-tists and 2 new nurse practitioners.

More information available at www.mehaf.org.

reform. The safety net will continue to facemultiple challenges that must be addressedfor reform to be sustainable. It will need toimprove community-based coordination ofcare, including referrals, working relation-ships among primary care, specialty care andhospitals; to improve health information tech-nology for medical records and for trackingcosts; to improve the overall experience ofpatients and to ensure cost effectiveness.69

Grantmakers can support outreach pro-grams for the remaining uninsured, the devel-opment of delivery systems like medicalhomes, better referral mechanisms, efficientuse of information technology and a costcontainment strategy to ensure a smoothtransition to a new safety net.

A significant part of safety net care isprovided by hospitals with financial assis-tance policies. These community benefitsare part of a nonprofit hospital’s obligationto the community that gives it a nonprofittax rate, a role that is reaffirmed and clari-fied through the ACA. The law promotestransparency about hospital care policies,billing and debt collection. Much, however,is left to interpretation and to practical

implementation on the ground. CommunityCatalyst, a leading health advocacy groupbased in Boston, has clearly defined thelines between the law and its implementa-tion and offered advice to advocates work-ing on this part of the safety net.70

In Minnesota, Allina Hospitals and Clinicsput their community benefits obligations intoaction by literally looking into their ownbackyard and learning to listen (see Spotlight).Allina’s Backyard Initiative fulfills andexceeds its community benefit obligations tothe community’s safety net by addressing rootcauses of poor health outcomes, includingsocial determinants and involving the voicesof the community in decision making.

Aside from the exemplary funders notedin this text, this report is coupled withNCRP’s evidence-driven contention that itsvalues and principles for exemplary philan-thropy could be of assistance to many othergrantmakers who wish to affect health out-comes and to support the implementation ofhealth reform. “Spotlight: First Steps TowardTransformative Grantmaking” (page 30) positssome ideas for grantmaking that reflect theseprinciples.

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Christiana Care's Community Outreach team and members of the Wilmington Hospital staff were among the more than 50 hospitalvolunteers offering Wilmington residents free health screenings and health information at the 2008 Wilmington Wellness Day.Photo courtesy of Christiana Care Health System.

SPOTLIGHT: The Backyard Initiative (Allina) — A Community-Corporate Partnership to ImproveHealth in Minnesota

In the spring of 2008, as part of their community benefits work, the Allina Hospitals andClinics looked at their backyard, the approximately one square mile around Allina’s corporateheadquarters in Minneapolis, Minn. Nearly half of Allina’s 23,000 employees work there andsome 500 live there.

Allina also is home to one of the most racially diverse communities with a population that is32 percent white, 26 percent African American, 22 percent Hispanic and 7 percent NativeAmerican. One-fourth of the community is foreign born. The unemployment rate is twice thestate rate and 44 percent of the community is low-income.

Despite living in such close proximity to a world-class medical center, many residentsexperience poor health outcomes and difficulty obtaining affordable health insurance. Inthe process of community involvement, one member said, “We have more than we know;we know more than we say; we say more than you hear. Talking must be accompanied bylistening.”

Allina listened. The hospital partnered with the Cultural Wellness Center in southMinneapolis to hold community meetings in which residents developed a holistic defini-tion of health, emphasizing the “connectedness within and among many systems – thebody, the family, the community, the envi-ronment and culture.”

By 2009, the initiative had developedprinciples that hold it together, includingfull participation of community residents inassessments of and decisions about theircommunity. Allina also convened listeningcircles and conducted random interviews toassess the current state of health and well-being of the residents. Allina published theresults in a 32-page report, which identifiedlimitations to the residents’ definition ofhealth and set benchmarks to measurefuture improvements.

The Backyard Initiative became part ofAllina’s $50 million commitment to commu-nity health improvement, “The Center forHealthcare Innovation.” The initiative embod-ies principles of systems theory and targeteduniversalism.

More information available at: http:/ /www.allina.com/ahs/cmtybenefit.nsf/page/Backyard_Initiative_Assessment_Report_April_2010.pdf/$FILE/Backyard_Initiative_Assessment_Report_April_2010.pdf.

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The United States’ high rate of spending onhealth care, now approaching well above 17percent of GDP, irrefutably puts our nation ata competitive disadvantage in world markets.Professor Peter Morici of the Robert H. SmithSchool of Business of the University ofMaryland contrasts the U.S. figure with thatof Germany, where health care accounts for12 percent of GDP, noting that “the UnitedStates simply can’t afford that competitivedisadvantage.”71

China, too, is reforming its health caresystem based on a market system. “ChinaSees Challenge on Health System,” an articlein The Wall Street Journal from September2010, should give any funder pause. Ourhealth reform effort is aimed at expandingcoverage to approximately 32 million peopleand instituting structural changes in work-force, delivery systems and public health fora price tag of up to a trillion dollars. China,the Journal reported, is in “the first phase ofits $125 billion plan to provide affordablemedical care for the entire population by2020. China is striving by the end of nextyear [2011] to offer basic medical coverageto more than 90 percent of its residents. Italso aims to improve the primary-care systemand equalize public-health services acrossthe nation.”

The article reported that China spent morethan $10 billion within the preceding year toexpand basic medical coverage and providereimbursement for medical expenses of up to60 percent for 833 million people. ChineseMinister of Health Dr. Chen commented,“‘Health-care reform is by no means an easyjob for [any] country, particularly for a coun-try of 1.3 billion people.”72

The core challenge for the United States isto organize the health and health care sectorsof American society in such a manner that

they address key human concerns as factorsof economic efficiency and productivity. Wewill continue to undermine our global eco-nomic competitiveness if we fail to do so.

The Affordable Care Act achieves some-thing crucial in this regard because it inte-grates the belief of the American people infairness with their support for the marketeconomy. Economist Alice Rivlin, formervice chair of the Federal Reserve and formerdirector of the Congressional Budget Office,maintains that the rhetoric of the reformdebate set up a false dichotomy betweenadvocates for market solutions, choice andcompetition on the one hand, and advo-cates for government intervention and regu-lation on the other: “Markets do not func-tion efficiently unless regulations ensure thatconsumers have access and comprehensivechoices and producers are actually forced tocompete.”73

Further, a well-implemented ACA can usethe forces of competition, information, con-sumer support and inclusion of people ofvaried incomes and occupations in arevamped system that provides better healthcare, produces better health outcomes andcosts less: “Advocates of market solutionsmust understand that the alternative to regu-lated markets is not the status quo. The statusquo encourages inefficiency, uneven quality,soaring costs and declining coverage.”74 Thestatus quo is not only untenable; it is eco-nomically perilous.

Health reform also affords the country achance to alleviate poverty on a scalebroader than what health care alone can doby integrating benefits and streamlining theaccess of benefits. The Centers for Medicareand Medicaid Services are supporting “verti-cal” connections among Medicaid, theChildren’s Health Insurance Program, the


VI. An Economic Necessity

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exchanges and employer-based insurancewith subsidies, which would intersect with“horizontal” connections among federalprograms such as the SupplementalNutrition Assistance Program, TemporaryAssistance for Needy Families, and theEarned Income Tax Credit.

The California Healthcare Foundation cre-ated and spun off a nonprofit (Social InterestSolutions) to tackle the problem of integratingbenefits. Currently, Social Interest Solutions isworking with the states of Arizona andMaryland to integrate their benefit systems.

Ford Foundation and the Open SocietyFoundations are supporting the work of theCenter on Budget and Policy Priorities andthe Urban Institute in similar work.

Local grantmakers can take the structuralinnovations being tested by their nationalpeers and apply them at the state and the

community levels. For instance, the FoodResearch and Action Center and partnerstates are developing ways to integrateaccess to food stamps; the Women, Infantand Children’s (WIC) program; summer andschool breakfast feeding programs andMedicaid. Funders can join this work by fos-tering links between state agencies and com-munity-based organizations that deliver serv-ices, such as members of United Ways, areaagencies on aging, child care centers orlocal pharmacies.

Addressing the structural barriers toaccessing benefits is a matter of fairness aswell as economic prudence, according toLuis A. Ubiñas, president of the FordFoundation, who states that a 100 percentuptake in benefits would be comparable toanother economic stimulus.75

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This report provides several examples offoundations and health care providers that havedemonstrated exemplary use of NCRP’s Criteriafor Philanthropy at Its Best. They know, as onefunder articulates, “Grantmaking is not an endin itself. It is a tool. The end is transformation.”76

Place-based initiatives, empowering com-munities, investing in people, supporting advo-cacy, organizing and the development of poli-cy, making the business case for comprehen-sive approaches to care – all serve as modelsfor support that any foundation can follow.

Health and human service foundationshave played a crucial role in supplementingpublic sector health initiatives. Health grant-makers now face a historic opportunity to cre-ate lasting changes in one of the largest sectorsof society. However, they need to act boldly.

NCRP’s ongoing Grantmaking forCommunity Impact Project released recently itsmultistate report on the impacts of advocacy,organizing and civic engagement in theNorthwest region. Collectively, 20 organiza-tions working in four states won more than $5

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VII. Towards Transformative Grantmaking

Despite expansion of health care access since its founding in1996, the Consumer Health Foundation (CHF) in Washington,D.C., saw health disparities in its community increase. Inresponse, CHF revised its mission “to achieve health justice asboth a goal and a framework for understanding and address-ing the ways in which health is determined by social, econom-ic and political forces, including how structural racism affectsthe health of communities of color.”

Structural racism refers to “a system of social structuresthat produces cumulative, durable, race-based inequalities.”79

Five questions that CHF President Margaret O’Bryonand former Board Chair Diane Lewis answer can guideother philanthropies as they seek to adopt a more holisticunderstanding of health funding. The questions, withshortened answers, are:

What motivated CHF to begin focusing on health justiceto improve community health?• “Community Health Speak-Outs” that garnered the sto-

ries and ideas of more than 500 community membersover a period of two years.

• The Social Determinants of Health, a public healthframework, that demonstrates how social and econom-

SPOTLIGHT: A Holistic Journey to Health Justice —the Consumer Health Foundation78

ic factors determine the well-being of indi-viduals and communities.

• Data, particularly from the federal govern-ment’s Healthy People 201080 report, thatshowed a worsening gap in health out-comes between whites and people of color.

How did CHF start the process of integratinghealth justice into its work?• CHF piloted the Racial Justice Grantmaking

Assessment of the Applied Research Centerand the Philanthropic Initiative for RacialEquity. This led CHF to develop a logicmodel and a theory of change to reflect itscommitment to health justice.

• CHF created Wellness Opportunity Zones(WOZs), place-based initiatives seeking totransform a community’s overall environ-ment in order to improve health.

• CHF partnered with Grantmakers InHealth to direct attention to the issue ofHIV and women of color: 90 percent ofwomen with AIDS in D.C. are black.

billion in benefits for disadvantaged groups andthe broader public over the five-year time peri-od studied. For every dollar invested in thispolicy engagement work, the return on invest-ment was $150. The Washington CommunityAction Network (WCAN!) achieved a signifi-cant victory when it won the WashingtonPrescription Drug Card campaign, a multistatepurchasing pool that makes prescription drugsmore affordable. Had foundations not investedin this organization’s policy engagementcapacity, WCAN! would have faced a majorresource deficiency and been unable to chal-lenge the powerful influence of the pharma-ceutical industry’s lobbyists.77

For foundations to employ the values andprinciples emphasized in this report, they notonly need to act more boldly in their choiceof grants and grantee organizations; they alsoneed to look closely at their own practices

and internal structures. “Spotlight: A HolisticJourney to Health Justice — the ConsumerHealth Foundation” presents the example ofa foundation on a journey to achieve justicewithin its own walls and to carry that justiceinto its community. It begins with the boardand staff working as partners.

One seasoned grantmaker of 30 years, lis-tening to a discussion of the recurring difficul-ties of getting poor children adequate nutrition,once remarked to the author of this report,“We do love the problem, don’t we?” As asociety, as foundations or as non-profits, thetemptation may be to love the problem, what-ever it is, such that one never really gets tosolutions. Reaching solutions might require thatone alter the definitions, advocate for shifts inpower relationships or take some real risks.

Geography and certain issues betray anaversion to risk-taking: many funders avoid

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How are you addressing structural racismthrough your work?• “Changing the Conversation on

HIV/AIDS,” a community meeting, soughtto understand HIV/AIDS as a symptom ofthe larger social conditions of women’slives.

• Supporting advocacy: training young peo-ple as advocates to dismantle the web ofstructural racism and funding more than34 organizations to advocate for policychanges at the local, state and regionallevels.

What are the challenges involved in fundingand engaging in health justice work? Is it dif-ficult work for philanthropy to support?• Self-assessment is the most difficult part

for any foundation. Despite all the goodwork, if health outcomes continue toworsen, you must start asking tougherquestions.

• The board and the staff worked together tofind the right path and then they lookedfor partners – with other funders, govern-ment, advocates and the community.

• Broadening traditional definitions of

health to include social determinants such as housingand the environment, which is a challenge for philan-thropy.

What does this work look like going forward? What areCHF’s short- and long-term goals?• The logic model and theory of change guide us, and

we’re going to put indicators and data around ourshort-term outcomes, but this is a long and evolvingprocess.

• We’re expecting others to join us on this journey.

Grade school children get involved in an event by “Let's Get Healthy,”a pilot project of Mary's Center for Maternal and Child Health in 2005.The project received funding from the Consumer Health Foundation.Photo by Michael Bonfigli.

rural areas, conservative states, the Southand marginalized communities, especiallyundocumented immigrants. While dis-cussing risk, foundations in fact supportwork that will more likely bring them posi-tive results. Ready outcomes and short-termfocus are celebrated at the expense of theadvocacy and community organizing workthat requires patience but achieves long-term change.

In this era of global competitiveness andin the face of the United States’ significantchallenges with regard to human services, itis time to focus on the most disadvantagedand to support the efforts of those working incommunities and with community people.The United States has the knowledge and theskills to create an efficient health care systemand to eradicate inequities. Foundations canplay a critical role in creating such a system.

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SPOTLIGHT: First Steps Toward Transformative Grantmaking1. Consider initiating “place-based” work in your community

• Focus on a marginalized group(s) with your grantee partners.• Listen to community members.• Build shared purpose to encourage ongoing civic engagement.• Confront racism and barriers to equality directly.

2. Work collaboratively • Partner with other foundations, state and local government and local,

state and national advocacy organizations. • Support organizing and advocacy: find out which organizations work

in your state on disparities and inequities, and health outcomes.• Support organizations that lead the community in policy engagement.

3. Learn about health reform activities in your state government • Check with state officials to see what their capacity is for implementing reform: consider providing

personnel support, expert technical assistance, data gathering and analysis, help with public educa-tion and communications.

• Replicate proven approaches to community prevention and support innovation.

4. Work on select aspects of reform• Ensure consumer input into the establishment of the exchanges.• Monitor the regulation of commercial health insurance.• Simplify and integrate eligibility systems for a range of benefits.• Gather useful data, turning reliable analyses around quickly.• Expand health system and provider capacity: the supply of primary care providers, scope of practice

laws, team approaches to care delivery.• Attend to the design of benefits.• Focus on chronic disease and the dually eligible for Medicare and Medicaid.• Improve the overall health of the population: make the business case for chronic disease and popula-

tion health goals, get the public excited about a goal and pursue it.• Focus on delivery system reform: demonstrate how improvement in the delivery of public programs

can improve the entire health system.• Community benefits: learn about the improvements through the Affordable Care Act and what your

foundation can do to support a robust community benefits plan.

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To help health funders take the necessarysteps toward exemplary and responsive grant-making, health grantmakers and other fun-ders can consider the following questions fordiscussions within their organizations andamong their colleagues:• Does your foundation find systems theory

and systems thinking useful in thinkingabout health outcomes and health care inyour community and state? How can sys-tems thinking used by health funders helpcounteract the fragmentation of the healthcare system?

• What marginalized communities exist inyour catchment area? Are there any com-munities that funders in your area havenot approached? Has your foundation eversupported convenings, community meet-ings or retreats?

• What percentage of your grant dollars isused to intentionally benefit underservedpopulations? How does that compare withexemplary grantmakers in your field?

• Does your foundation support communityorganizing? Are you familiar with theorganizing groups in your area and haveyou sought them out to learn about theirwork? What are the obstacles that mayhold you back from supporting organiz-ing?

• Does your foundation support advocacy?If not, have you ever sought out the adviceof other funders and national organiza-tions that do support advocacy? What typeof health care advocacy organizationsexists in your state and community?

• Have you turned to local or state expertsfor information on the health reform law?What is your state’s position on the imple-mentation of the ACA? How can you findout? Does your foundation have a positionand is it public?

• Do you see connections among nationaladvocacy, statewide advocacy and localimplementation? What national founda-tions are working in your state on healthreform or on improving health in commu-nities?

• Does your foundation support civicengagement? If so, what forms does thesupport take? If not, please consider whynot.

• Does your foundation reflect the values offull participation and inclusion of every-one within its own walls? Do the boardand staff work toward common goals? Dothey work in the context of mutualrespect?

• What other foundations does your founda-tion communicate and collaborate with?Does your foundation seek informationand insight from established resourcessuch as your local regional association ofgrantmakers or organizations likeGrantmakers In Health?

CURRENT TRENDS IN HEALTH GRANTMAKINGTo help inform those discussions, NCRP con-ducted a detailed analysis of the most recentdata available from the Foundation Centerabout domestic health grantmaking. It exam-ined 880 foundations that made grants todomestic health over a three-year periodfrom 2007-2009. NCRP worked with customdatasets developed with the FoundationCenter, which include detailed informationon more than 1,200 of the largest founda-tions in the United States. The search sets arebased on the Foundation Center’s grants sam-ple database, which includes all grants of$10,000 or more awarded to organizationsby a matched sample of 880 larger founda-

VIII. Making this Report Relevant to YourFoundation

tions for circa 2007–2009 that made grantsclassified as supporting health. For communi-ty foundations, only discretionary and donor-advised grants are included. Grants to indi-viduals are not included in the data. TheFoundation Center’s grants sample databaserepresents at least 50 percent of U.S. grant-making, allowing for broad field-wide trendsto be gauged.

Grants were analyzed by intended benefi-ciary to determine the proportion of them thatwere classified as intending to benefit “mar-ginalized” or “underserved” populations.81

Further, grants were analyzed using theFoundation Center’s “social justice” screen todetermine, as closely as possible, whichhealth grants had systemic change as a goaland, as such, likely included funds for advo-cacy, community organizing and civicengagement.

All figures presented in the analysis ofhealth funding below represent a three-yearaverage of giving from the 2007–2009 time-frame. NCRP uses a three-year average in itsdata analyses to avoid the influence of poten-

tial outliers, e.g., a large grant made only inone year that could influence the data. Itthen examined only those grantmakers thatmade an average of $1 million or more annu-ally in grants for health over the three-yearperiod to see if patterns held among largerhealth grantmakers.

In the aggregate, the 880 foundations inthe sample granted out an annual averagetotal of $14,721,830,985. Of this, a total of$2,600,230,665 was coded for domestichealth, comprising just under 18 percent oftheir total giving. Total average giving by the363 grantmakers who made at least an aver-age of $1 million in domestic health grantsannually was $10,469,768,342, of which$2,451,179,600 was granted out for domestichealth. For this subset of funders, healthgrants accounted for nearly one-quarter oftheir total giving in the time period analyzed.

Among the 880 grantmakers in the sam-ple, 274 foundations or 31 percent of thesample met the 50-percent threshold for giv-ing intended to benefit disadvantaged groupsand 39 of these grantmakers (4 percent) clas-

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TABLE 1: NCRP Analysis of Health Funding

Sample foundations giving anaverage of $1 million or more

Full sample annually for domestic healthNumber of Foundations 880 363

Total Average Grant Dollars $14,721,830,985 $10,469,768,342Total Average Grant Dollars

to Domestic Health $2,600,230,665 $2,451,179,600Percentage of Total Average

Grant Dollars to Domestic Health 17.66% 23.41%

11%GRAPH 6: How Much

Domestic Health Grantmaking

Goes to Social Justice?

39%

GRAPH 5: How Much Domestic Health Grantmaking Goes to Benefit Marginalized Communities?

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TABLE 2: How Many Foundations Meet NRCRP’s Benchmarkson Support of Marginalized Communities and Social Justice?

Sample foundations giving anaverage of $1 million or more

Full sample for domestic health annuallyNumber of Foundations 880 363

Number of Foundations Contributing 50% or More of Domestic Health Grant Dollars

to Benefit Marginalized Communities 274 101 Number of Foundations Contributing

25% or More of Domestic Health Grant Dollars to Social Justice 39 25

Number of Foundations Meeting Both Benchmarks 35 22

GRAPH 7: How ManyFoundations Provide Half of Domestic Health Grant Dollars to BenefitMarginalizedCommunities?

GRAPH 9: How ManyFoundations MeetBoth Benchmarks?

GRAPH 11: How ManyFoundations with atLeast $1 Million inAnnual Domestic Health GrantmakingProvide 25% in Social Justice?

GRAPH 8: How ManyFoundations Provide

25% of DomesticHealth Grant Dollars

in Social Justice?

GRAPH 10: How ManyFoundations with at

Least $1 Million inAnnual Domestic

Health Grantmaking Provide Half to Benefit

MarginalizedCommunities?

GRAPH 12: How ManyFoundations with at

Least $1 Million inAnnual Domestic

Health GrantmakingMeet Both

Benchmarks?

31%

7%

4%

4%

28%

6%

Considering the disparities in health and health care described in

this report, it is encouraging that a solid proportion of foundations

are operating in ways likely to produce the greatest impact.

sified 25 percent or more of their domestichealth grant dollars as serving a social justicepurpose. In this group, 35 foundations (4 per-cent of the sample) met both metrics. (If youwant to know how your foundation scores onthese benchmarks using Foundation Centerdata, contact [email protected] and NCRPwill be happy to share with you the data con-cerning your foundation.)

Among the 363 grantmakers that providedat least $1 million in average annual healthgrant dollars, 101 foundations or 28 percentof the sample met the 50 percent thresholdfor giving intended to benefit disadvantagedgroups and 25 of these grantmakers (7 per-cent) classified 25 percent or more of theirdomestic health grant dollars as serving asocial justice purpose. Of funders that pro-vided an average of at least $1 million fordomestic health each year, 22 foundations or6 percent of the sample met both metrics (afull list of these grantmakers is providedbelow). It appears that larger health grant-makers (those making more than $1 millionin average annual health grants) are slightlymore likely to meet both benchmarks thansample foundations generally.

These 22 exemplary funders exhibit strate-gic grantmaking in action, demonstrating thatthe metrics NCRP proposed are both achiev-able and sustainable. Moreover, the 22 fun-ders represent variable types of foundations –independent, family,82 corporate and healthconversion foundations,83 suggesting that themetrics are adaptable, regardless of institu-tional type.• BlueCross BlueShield of North Carolina

Foundation• The California Endowment• The California Wellness Foundation• The Caring Foundation (Ala.)

• The Annie E. Casey Foundation• The Colorado Trust• The Nathan Cummings Foundation• The Educational Foundation of America• Endowment for Health, Inc.• Ford Foundation• Richard and Rhoda Goldman Fund• The William and Flora Hewlett Foundation• W. K. Kellogg Foundation• The John D. and Catherine T. MacArthur

Foundation• The John Merck Fund• Charles Stewart Mott Foundation• Open Society Foundations• The David and Lucile Packard Foundation• Public Welfare Foundation, Inc.• Quantum Foundation• The Retirement Research Foundation• The Rockefeller Foundation

These are not, of course, the nation’s onlyexemplary health funders. Some of the besthealth funders are too small to be included inthe Foundation Center’s data. And someremarkable larger funders do not meet thebenchmarks but nevertheless do great work.The point is to add some rigor and somebenchmarking to the discussion, so that allhealth funders can be more strategic andmore responsive.

NCRP’s principles from Criteria forPhilanthropy at Its Best were meant to applyto an entire foundation’s activities, not only toone program area. But considering the dispar-ities in health and health care describedthroughout this report, it is encouraging that asolid proportion of foundations are operatingin ways likely to produce the greatest impact.

NCRP is truly pleased at the high levelsof priority that health grantmakers appearto place on funding for disadvantaged pop-

34


ulations and policy engagement work.Some funders, for example, may employthese strategies – targeted universalism andsystemic change approaches – but may doso with a relatively small portion of theirhealth grant dollars. Knowing these per-centages might help a foundation makebetter decisions.

Presented below in alphabetical orderare profiles of five of the 22 exemplarygrantmakers. They dedicated at least half oftheir average annual grant dollars fordomestic health to explicitly benefit under-served populations, and at least one-quarterfor “social justice” purposes, suggesting acommitment to systemic change and a highpriority being placed on advocacy, commu-nity organizing and civic engagement work.NCRP is highlighting these five grantmakersbecause they represent different types ofinstitutional grantmakers (private, health-conversion, corporate and family) and arespread across the country.

Some of these exemplary grantmakershave an explicit focus on health, while othersmade health grants that complement differentpriority areas within their portfolios. Thereare multiple entry points to being a healthfunder, and the issues facing underservedpopulations are complex, interrelated andmultifaceted.

THE NATHAN CUMMINGS FOUNDATIONNew York, N.Y. • www.nathancummings.org

Founded in 1949, the work of The NathanCummings Foundation (NCF) is “rooted inthe Jewish tradition and committed to demo-cratic values and social justice, includingfairness, diversity and community. It seeks tobuild a socially and economically just societythat values and protects the ecological bal-ance for future generations; promoteshumane health care and fosters arts and cul-ture that enriches communities.”

Working across multiple issues, this pri-vate family foundation’s goals for its healthgrants are to ensure access for all Americansto high quality and affordable health care

and to create a healthier, more equitable andsustainable quality of life. Its three objectivesinclude: health access, environmental healthand capacity building. NCF demonstrates areal understanding of the intersection of vari-able strategies and tactics needed for long-term, systemic reform and thus supports insti-tutional reform and policy engagement workto meet its first objective.

For example, in 2008, NCF provided a$255,000 grant to the Center for Rural Affairsin Lyons, Neb., to broaden and enrich ruralengagement in the public debate over ensur-ing access to high quality, affordable healthcare for all. Rural America faces a unique setof challenges: residents have less access tohealth networks and providers, greater ratesof disability and chronic disease, lessemployer-provided health coverage and high-er usage rates of use of all public health careprograms than other Americans. With sus-tained funding, NCF has helped the Center toleverage and expand its network and enabledit to play a key role in advocating forimproved health outcomes for rural popula-tions in the Midwest and plains states. This isexemplary philanthropy because it recog-nized the special needs of a specific con-stituency often overlooked in all grantmakingand provided sustained funding to build localcapacity, thereby ensuring continued success.

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NCF’s health program director, Sara Kay,explains this grantmaker’s decision to fundintentionally the work of a rural group:

“The 50 million people in ruralAmerica had not, for the most part, beendirectly engaged by the major consumeradvocacy groups working on structuralreform issues. The Center for Rural Affairshas tremendous credibility on a range ofrural issues among policymakers, advo-cates and the public from its many yearsof working on the farm bill and other agri-cultural development matters, but it hadnot previously worked on health careissues. Recognizing its nascent capacity tocontribute to health improvements,Nathan Cummings gave the center one ofits first health care grants.”

THE ENDOWMENT FOR HEALTHConcord, N.H.www.endowmentforhealth.org

Founded in 1999, the Endowment for Healthworks “to improve the health and reduce theburden of illness for the people of NewHampshire – especially the vulnerable andunderserved.” This health conversion founda-tion focuses on the health needs of marginal-ized communities because of its values.Foundation President James Squires notes,“We have a set of six values that were creat-ed four years ago by the board and staff. Theresult was an ethical foundation that guidesall of the endowment’s work. Our values ofintegrity, stewardship, fairness, respect, com-passion and courage are universal and informeverything we do.”

Vice president and COO Mary Vallier-Kaplan expanded on the importance of thefoundation’s values, stating that this links withthe organization’s funding of advocacy, organ-izing and civic engagement work. As Kaplanstates, “Policy engagement work on behalf ofvulnerable communities requires courage. Wefeel it’s a responsibility and it’s what philan-thropy is uniquely able to do, compared toother sectors. While the money we invest in

projects is important, leveraging our voice hasbecome a tool far greater than we anticipated.”

This leveraging of voice is elucidated in thefoundation’s funding of the In SHAPE program.The Endowment for Health was approached bya local nonprofit community mental healthleader who shared his concern that the averagelife expectancy of his clients with severe men-tal illnesses was 20–25 years less than forhealthy individuals. Realizing the myriad waysin which mental illness limits life opportunitiesand leads to premature death, the foundationshared this leader’s sense of responsibility toaddress this disparity and took action, says pro-gram director Jeanne Ryer. The mental healthcenter funded by the foundation created areimbursable Medicaid model that is beingreplicated in many states. It brought together arange of partners, including the Robert WoodJohnson Foundation, the Substance Abuse &Mental Health Administration (SAMSHA) andthe National Institute for Mental Health(NIMH), which saw the potential of partneringwith a local funder to develop a scalablemodel. The project worked with communitygroups such as the local college and YMCA tohelp those with severe mental illnesses takecharge of their own health, integrate into com-munity life and help alleviate the persistentstigma attached to mental disability.

Vallier-Kaplan noted the numerous partner-ships across different levels that evolved fromthis work – local and national philanthropies,public and private sectors, local leadershipand clients of the mental health centerworked together to develop what is expectedto become a nationally reimbursable model.

“This is the core idea – it’s the role of afoundation that realizes there’s a populationthat doesn’t receive fairness, respect andcompassion,” says Kaplan, tying this workback to the foundation’s values. “A founda-tion should take risks with a population thatisn’t one that people naturally want to dealwith in an integrated approach.”

Noting the importance of including com-munity advocacy groups and constituents fromthe outset, she added that the work requiredpatience and persistence. “We invest$400,000 a year to provide operating grants

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“

with five-year commitments to statewide advo-cacy, knowledge and capacity building organi-zations early on because these organizationsshouldn’t go off-mission. We trust them.Everyone else in the system needs them.”

Working in true partnership with itsgrantees, Ryer adds, “If a small funder can dothis, it shows larger ones the importance oftrust and community engagement as a tool toadvance social inclusion through healthgrantmaking.”

THE W.K. KELLOGG FOUNDATIONBattle Creek, Mich. • www.wkkf.org

The W.K. Kellogg Foundation’s mission is tosupport “children, families and communitiesas they strengthen and create conditions thatpropel vulnerable children to achieve successas individuals and as contributors to the larg-er community and society.” Health grantmak-ing comprises more than one-fifth of its totalgrantmaking portfolio.

The foundation adopted recently a newframework for its programming thatacknowledges explicitly the complexitiesand interrelated issues such as health edu-cation and employment that impact thechances of changing life opportunities forvulnerable children. This new frameworkincludes programmatic foci on food,health and well-being coupled with anexplicit focus on eliminating structuralracism in pursuit of racial equity. Kelloggemphasizes the importance of communityengagement to create long-term solutionsto systemic problems and encourages civicengagement and democratic participationto this end. The new framework aims “tohelp children face the future with confi-

dence, with health and with a strong-root-ed security in the trust of this country andits institutions.”

Dr. Gail Christopher, vice president forprogram strategy, oversees the foundation’sFood, Health and Well-Being work in addi-tion to its racial equity efforts. DiscussingKellogg’s food systems reform work, shenotes that while it was previously a separateprogrammatic area, it is now coupled inten-tionally with the health program’s workbecause the two are interconnected.

The Food and Community Programinvolved working in nine communities wherea significant portion of the funding was forcommunity organizing. In Oakland, youngpeople and residents conducted an environ-mental scan of available food to determinethe cost and availability of healthy foods. InSeattle–King County, youth developed a foodtable where they convene 30-40 young resi-dents on a weekly or monthly basis to eat ameal together and develop strategies forimproving access to healthy foods collective-ly. In New York and Boston, the foundationfocuses on local farmers and ensuring theavailability of healthy food in urban areasand schools.

“It’s about being fair to producers andproviding access to healthy food alterna-tives to people and communities regardlessof income,” says Dr. Christopher. “You cantalk about obesity reduction but if youdon’t talk about it in the context of com-munities, it’s a ‘disease conversation’; wehave medicalized a problem that is in facta social justice issue that has some medicaland public health dimensions, whichbrings us right to the social determinants ofhealth,” she adds.

W.K. Kellogg-funded Place Matters work

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We have medicalized a problem [obesity] that is in fact a social issue that has

some medical and public health dimensions, which brings us right to the social

determinants of health.”

— Dr. Gail Christopher, Vice President for Program Strategy, W.K. Kellogg Foundation

“

at the Joint Center Health Policy Institute ref-erenced earlier in this report involves 21communities nationwide in partnerships thatapply the social determinants of health toimprove health outcomes in areas articulatedby the communities.

Discussing the link between the founda-tion’s racial equity and health work, Dr.Christopher emphasizes the importance offraming. They are working to remind peoplethat the racial dynamic, the lack of racialequity is a life and death issue. “It’s a healthissue too, which we call disparities,” shesays. “One of the reasons that the equitywork is framed as racial healing work is thatpeople have to come to a willingness to seethe urgency and the persistence of the atti-tudes and perceptions that lead to the struc-tural realities, and they have to have the will-ingness to do the work to change that. Thisrequires a change of heart.”

THE JOHN MERCK FUNDBoston, Mass. • www.jmfund.org

Founded by Serena S. Merck in 1970, TheJohn Merck Fund is a family foundationnamed for her son. Its sole founding missionwas addressing children’s developmental dis-abilities. Sixteen years later, the fund expand-ed its foci to include climate and clean ener-gy issues, a special Rural New England pro-gram and environmental health. The JohnMerck Fund embodies exemplary philanthro-py by focusing on vulnerable groups explicit-ly and recognizing the interrelated systems

confronting its constituents that influencetheir health.

The fund’s Environmental Health Programfocuses on preventing exposure to chemicalslinked to negative health outcomes. Thefund’s work on mercury pollution throughcoal-fired power plants revealed that thecommercial sector of the United States hasmore than 80,000 chemicals and that theyare not isolated to industrial sites. Rather,they are ubiquitous in consumer productsand the environment, allowing hundreds ofthese toxins to end up in our bodies.Shockingly, these chemicals are even foundin newborn babies.

Compounding this situation is the fact thatthe government regulates chemicals in a“one-by-one approach,” reinforcing the needfor a systematic approach to regulation, simi-lar to those in Europe and Canada. The fundset a goal of developing a comparable policyfor the United States to ensure that no chemi-cals would be marketed until proven safe,with the responsibility for ensuring publicsafety lying with the manufacturer and not onthe public sector. This goal was well-alignedwith the fund’s traditional interest in amelio-rating developmental disabilities, as scientificresearch revealed additional correlationsbetween chemical exposure and health prob-lems ranging from Parkinson’s andAlzheimer’s diseases.

The fund devised an advocacy and policystrategy that engaged health advocacy organi-zations across campaigns in six states (Maine,Washington, Massachusetts, Connecticut,Michigan and Minnesota). In 2008, a broad

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You have to marry social services with advocacy in

health grantmaking; the social determinants of health

are far too important to use an either/or approach.”

— Ms. Irene Frye, Executive Director

The Retirement Research Foundation

campaign of women’s advocates, farmers,small businesses, health advocacy groups andmany others, The Alliance for a Clean andHealthy Maine, led by Maine’s EnvironmentHealth Strategies Center, resulted in the KidsSafe Products Act, the first law in the nationto approach chemical regulation in a com-prehensive way. This law is a model for legis-lation pending currently in the U.S. Houseand Senate.

The fund demonstrates an understandingof the complex and interrelated systems thatmarginalize Americans and jeopardize theirhealth. Ruth Hennig, executive director ofthe fund, explains, “Health is a huge moti-vator. Protecting your health and that ofyour family members is a critical goal forpeople across the board. If you’ve had alife-altering disease, you’re even more moti-vated to understand why this happened andto prevent others from having the sameunfortunate experience. Prevention is astrong motivating force.”

The John Merck Fund’s focus on preven-tion, systems reform, the appropriate balanceof service provision and advocacy and fund-ing of collective organizing demonstrates along-term commitment to sustainable healthimprovements and aligns well with imple-menting provisions of the Affordable Care Act.

THE RETIREMENT RESEARCH FOUNDATIONChicago, Ill. • www.rrf.org

The Retirement Research Foundation is anindependent grantmaker that has awardedgrants nationwide totaling nearly $200 mil-lion since 1978. Like many funders that havemade the decision to focus on vulnerablecommunities and to support advocacy, thefoundation traces these commitments to itsfounder. Established in 1950 by John D.MacArthur, the foundation initiated grant-making upon his death in 1978. MacArthurmade a “very forward-thinking” decision,says Executive Director Irene Frye, choosingto center its work exclusively on the needs ofthe elderly. The choice proved prescient, withthe first Baby Boomers reaching retirement

age today, and people over 85 years of agecomprising the fastest growing segment of theU.S. population.

The foundation’s original mission chargedit to address work-related problems con-fronting retirement age individuals “all forpublic welfare and for no other purpose.”Advocating for policy change to correctinjustices played an important role at thefounding. One of the foundation’s first goalswas to “support selected basic, applied andpolicy research that seeks causes and solu-tions to significant problems facing the aged.”

Recognizing that the issues confrontingretirement-aged constituents are multifacetedand complex, the foundation’s trustees refo-cused the mission in 2008 to concentrateespecially on those who – for reasons ofphysical frailty, economic disadvantage orracial or ethnic disparity – are particularlyvulnerable. Current foundation staffexplained that “The board has retained themoral imperative that the quality of a societycan be judged by how it treats people towardthe end of life,” says program consultantNaomi Stanhaus.

Further, while the elderly comprise some13 percent of the population, Frye notesgrants in aging account for a mere 2 percentof philanthropic dollars. In surveying thelandscape of existing funding, the foundationdetermined that it could do more by focusingon advocacy.

The foundation’s approach to its grant-making is exemplary in many ways, particu-larly in its strategic and intentional comin-gling of service delivery with policy advoca-cy. It supported the coalition work of MakeMedicare Work and the Center for MedicareAdvocacy, using experiences of its con-stituents to identify training needs and drivesuccessful policy advocacy. As Frye stated,“You have to marry social services withadvocacy in health grantmaking; the socialdeterminants of health are far too importantto use an either/or approach. Moreover, itisn’t just advocacy by one foundation thatwill result in long-term systemic reform thatbenefits our constituents. It’s collectiveadvocacy that will ensure that the needs of

39


vulnerable elderly community members aremet in the future.”

The foundation recognizes that a certainlevel of risk-taking is associated with fundingadvocacy. However, as Frye stated, “Evenwhen our assets took a hit recently, we con-tinued providing substantial funding for poli-cy/advocacy work. There’s also a businesscase to be made for getting involved in fund-ing in this way – the high return on invest-ment. When you help one person, you helpone person. The whole opportunity of philan-thropy is to change things for many for thelong-term.”

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The health of the United States in itsbroadest sense is in jeopardy. The number ofuninsured Americans is at a record high, andpoor health outcomes are devastating thephysical and economic fabric of theAmerican people. Our most disadvantagedpeople continue to be treated poorly, includ-ing by our health care system. What wechoose to do about health outcomes and thehealth system is a major factor in how wewill emerge from the current economic crisis.

The American economy, private sectorbusinesses and American families are at anunsustainable level of health care costs, indi-vidually, socially and in the aggregate,because of a fragmented system. In relin-quishing so many to poor health outcomesand in continuing to cost so much, the sys-tem harms the American workforce andweakens the country’s ability to recover. Theinefficient and costly system was the impetusfor comprehensive health care reform legisla-tion. It is our responsibility and opportunityto fix this broken and inequitable way oforganizing health care. As we fix the system,we need to enable communities to developand use their knowledge and wisdom to leadhealthier lives.

When government functions resolutelyand effectively in the interest of the public,money is saved and community needs aremet. More than thirty years ago, for example,the state of Maryland instituted an all-payersystem for hospitals. The legislature left lee-way for hospitals and providers to work outthe details, but required them to work togeth-er under the regulation of a state agency.84 Ifthe United States had instituted equally effec-tive legislation at the same time, it wouldhave saved $2 trillion in hospitals costs.85 In1997, the federal government started theState Children’s Health Insurance Program

that has given coverage and care to millionsof children throughout the country.

Government can work effectively and weneed it to. Philanthropy needs to support andencourage the role of government to work inthe public interest and to support people’sparticipation in government at all levels. Ascommunities are organized and empowered,they come to believe that policy engagementis worthwhile. Their faith in the public sec-tor’s ability to respond to their needs couldalso be restored.

Foundations of all kinds have an unprece-dented opportunity to help address dispari-ties in health and health care, and to supple-ment public sector implementation of thenew law. Philanthropies experience a higherdegree of freedom than most organizations,and with that freedom comes a profoundresponsibility to help reverse the trends ofhealth inequality and to reinvest our healthsystem with the American ideals of fairness,justice and inclusion.

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IX. Conclusion

Our Health,Our Future

References

1. George C. Halvorson, Health Care Reform Now! A Prescription for Change (San Francisco: JohnWiley & Sons, 2007), p. 3.

2. Susan Dentzer, “Reform Chronic Illness Care? Yes, We Can,” Health Affairs 28, no. 1 (2009): p. 12.3. Thomas A. LaVeist, Darrell J. Gaskin, Patrick Richard, The Economic Burden of Health Inequalities in

the United States (Washington, D.C.: Joint Center for Political and Economic Studies, 2009).4. Niki Jagpal, Criteria for Philanthropy at Its Best: Benchmarks to Assess and Enhance Grantmaker

Impact (Washington, D.C.: National Committee for Responsive Philanthropy, 2009).5. In this approach, grantmakers design programs to intentionally benefit the most marginal. But in all

programs, every intended beneficiaries’ specific contexts/situations must be accounted for becausethey are very different, implying that any universal program that fails to account for individual con-text will likely miss its mark if it ignores the specific conditions of the people it seeks to help. Just asthe benefits of targeted universalism affect all of us positively, the negative consequences of persistentmarginalization also affect each of us negatively. So systems thinking and targeted universalismrequire us to understand the concept of “situatedness.” This concept simply means acknowledgingthe role that each individual’s life circumstances and environment play in determining their optionswith regard to life opportunities. So, for example, identifying the health and health care needs of anupper-middle class community is just as important as doing the same for a lower-income communitybecause the program design would need to be tailored to meet each of their specific needs. In short,a one-size-fits-all approach of a universal program offers less potential for impact than does grant-making that works in this framework. This is ever-more important as the country becomes morediverse and whites are no longer the majority because they are affected by how the majority, whichwill soon be non-white citizens, are faring.

6. John Gardner quoted by Bill Moyers, Remarks, 40th Anniversary of Common Cause (Washington,D.C., 2010).

7. Don Berwick, remarks at Grantmakers In Health Fall Forum, November 9, 2010.8. Martha Halko, Michele Benko, and The Land Use Committee, 2009 Cuyahoga County Health and

Land Use Summit Report, http://www.ccbh.net/ccbh/opencms/CCBH/pdf/communityhealth/2009SummitReport.pdf.

9. Bay Area Regional Health Inequities Initiative (2008),http://www.barhii.org/press/download/barhii_report08.pdf.

10. Anthony Iton, presentation at Consumer Health Foundation Annual Meeting, May 20, 2010.11. Anthony Iton, Op. Cit.12. David Williams, Manuela V. Costa, A. O. Odunlami and S. A. Mohammed, “Moving Upstream: How

Interventions that Address Social Determinants of Health Can Improve Health and ReduceDisparities,” Journal of Public Health Management and Practice, 14 (6) S8 – S17 (2008).

13. Bay Area Regional Health Inequities Initiative, Op.Cit., p. 8.14. California Newsreel, RACE – The Power of an Illusion (2003). Also please see, Grantmakers In

Health, “Racism: Combating the Root Causes of Health Disparities,” Issue Focus (Washington, D.C.,2010), April 19, 2010.

15. Dalton Conley, Transcript from RACE – The Power of An Illusion (2003),http://newsreel.org/transcripts/race3.htm.

16. Thomas Shapiro, Tatjana Meschede and Laura Sullivan, “The Racial Wealth Gap Increases Fourfold,”Research and Policy Brief (Institute on Assets and Social Policy, May 2010)http://iasp.brandeis.edu/pdfs/Racial-Wealth-Gap-Brief.pdf.

17. Kristen Lewis and Sarah Burd-Sharps, A Century Apart: New Measures of Well-Being for U.S. Racialand Ethnic Groups (New York: American Human Development Project, April 2010)http://www.measureofamerica.org/wp-content/uploads/2010/04/A_Century_Apart.pdf.

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18. Meizhu Lui, Laying the Foundation for National Prosperity (Oakland, CA: Insight Center forCommunity and Economic Development, 2009).

19. Kristen Lewis and Sarah Burd-Sharps, The Measure of America 2010–2011, Mapping Risks andResilience (New York, New York University Press 2010).

20. American Human Development Project calculations using mortality counts from the Centers forDisease Control and Prevention, National Center for Health Statistics. Mortality – All County Micro-Data File (2007), as compiled from data provided by the 57 vital statistics jurisdictions through theVital Statistics Cooperative Program.

21. “Place Matters,” Joint Center for Political and Economic Studies,http://www.jointcenter.org/hpi/pages/place-matters.

22. Bay Area Regional Health Inequities Initiative, p. 9.23. “Building Healthy Communities,” The California Endowment,

http://www.calendow.org/healthycommunities/.24. “Social and Cultural Barriers to Access,” Endowment for Health,

http://www.endowmentforhealth.org/about-us/our-mission-values-and-outcomes/our-priorities/social-and-cultural-barriers-to-access.aspx.

25. Darryl Fears, “At Duke, an experiment in community care,” The Washington Post, November 7,2010, A3.

26. Janet Corrigan and Dwight McNeill, “Building Organizational Capacity: A Cornerstone of HealthSystem Reform,” Health Affairs, March 2009 vol. 28 no. 2, p. 205.

27. Avery Johnson, “Recession Swells Number of Uninsured to 50.7 Million,” Wall Street Journal,September 17, 2010.

28. American Human Development Project, “Health Care Doesn’t Have to Cost An Arm and A Leg,”Social Science Research Council, March 11, 2010 http://www.measureofamerica.org/wp-con-tent/uploads/2010/03/29-Reasons-for-Optimism.pdf.

29. American Human Development Project, Op.Cit.30. Centers for Medicare and Medicaid Services, “National Health Expenditure Fact Sheet,”

https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp. 31. Kaiser Family Foundation, www.kff.org (2009).32. The White House Council of Economic Advisers, “The Economic Case for Health Care Reform,”

http://www.whitehouse.gov/administration/eop/cea/TheEconomicCaseforHealthCareReform/. 33. Kristen Lewis and Sarah Burd-Sharps, Op.Cit., p. 63.34. Wendell Potter, Deadly Spin, An Insurance Company Insider Speaks Out On How Corporate PR Is

Killing Health Care and Deceiving Americans (New York: Bloomsbury Press, 2010) p. 197.35. Consumer Health Advocacy, A View from 16 States (Boston: Community Catalyst, 2006).36. Grantmakers In Health, “Implementing Health Care Reform” (Washington, D.C.: Grantmakers In

Health, August 2010)http://www.gih.org/usr_doc/Implementing_Health_Care_Reform_August_2010.pdf.

37. Community Catalyst, A Path Toward Health Equity: Strategies to Strengthen Community Advocacy(Boston: Community Catalyst, 2010).

38. Kristen Lewis and Sarah Burd-Sharps, Op.Cit., p. 103.39. See http://dpc.senate.gov/docs/fs-111-2-101.html. You can view the full text of the Patient Protection

and Affordable Care Act at http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf .

40. Funders Committee for Civic Participation, “New GOP Governors Will Affect Health Law,” News &Resources, http://funderscommittee.org/resource/new_gop_governors_will_affect_health_law.

41. Henry J. Kaiser Family Foundation, “U.S. Health Care Costs,” Background Brief, March 2010,http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx.

42. Center on Budget and Policy Priorities, Community Catalyst, Families USA, Center for Children andFamilies, Health Care for America Now!, Trust for America’s Health, Where the Rubber Meets theRoad (Boston: Community Catalyst, 2010) p. 15.

43. Community Service Society of New York and Community Catalyst, Making Health Reform Work:State Consumer Assistance Programs (New York: Community Service Society of New York, 2010)http://www.cssny.org/userimages/downloads/Making%20Health%20Reform%20Work%20Sept%202010%20final.pdf.

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44. Community Catalyst, Op.Cit., p. 4.45. Karen Pollitz, Remarks at Grantmakers In Health session, “Building Health Advocacy Capacity at

State and Local Levels,” September 23, 2010.46. Wendell Potter, remarks at Politics and Prose, Washington, D.C., November 10, 2010.47. Linda Usdin, “Power Amidst Renewal: Foundation Support for Sustaining Advocacy after Disasters”

(Washington, D.C.: Alliance for Justice, September 2010) pp. 15–17.48. The Open Society Institute now is called “Open Society Foundations.”49. John Holahan, Dawn M. Miller and David Rousseau, “Dual Eligibles: Medicaid Enrollment and

Spending for Medicare Beneficiaries in 2005,” Issue Paper (Washington, D.C.: Kaiser Commission onMedicaid and the Uninsured, Kaiser Family Foundation, February, 2009)http://www.kff.org/medicaid/upload/7846.pdf.

50. “The Urgent Need for Better Care,” Campaign for Better Care,http://www.nationalpartnership.org/site/PageServer?pagename=cbc_intro_landing.

51. CW Cranor, BA Bunting, and DB Christensen, “The Asheville project: long-term clinical and econom-ic outcomes of a community pharmacy diabetes care program,” Journal of the American PharmacistsAssociation 43(2): 173-184 (2003).http://www.pharmacytimes.com/files/articlefiles/TheAshevilleProject.pdf.

52. Dennis P. Adrullis, Nadia J. Siddiqui, Jonathan P. Purtle, Lisa Duchon: Patient Protection andAffordable Care Act of 2010: Advancing Health Equity for Racially and Ethnically Diverse Populations(Washington, D.C.: Joint Center for Political and Economic Studies, 2010).

53. Op.Cit., page 3. 54. “Human Capital,” Robert Wood Johnson Foundation, http://www.rwjf.org/humancapital/.55. Fact Sheet: TCWF Public Education Campaign - Increasing Diversity in the Health Professions, The

California Wellness Foundation,http://www.calwellness.org/health_issues/diversity_in_health_fact_sheet.htm.

56. “Prevention and Public Health Fund,” Health Reform GPS, Navigating Implementation, May 17,2010, http://www.healthreformgps.org/resources/prevention-and-public-health-fund/.

57. Jeffrey Levi, “Trust for America’s Health,” presentation to the Health Foundation of South Florida,October 2, 2010.

58. Billie Hall, “Giving Voice: The Power of Grassroots Advocacy in Shaping Public Policy,” Views fromthe Field (Washington, D.C.: Grantmakers In Health, November 15, 2010)http://www.gih.org/usr_doc/Grassroots_Advocacy_Sunflower_Foundation_November_2010.pdf.

59. Thomas Aschenbrenner, “Lights, Camera, Take Action: Spotlighting Public Health for the NextGeneration,” Views from the Field (Washington, D.C.: Grantmakers In Health, October 18, 2010)http://www.gih.org/usr_doc/Public_Health_Next_Generation_NWHF_October_2010.pdf.

60. Chris J. Wiant, “It Takes Many Villages to Create a Public Health Improvement Plan,” Views from theField (Washington, D.C.: Grantmakers In Health, June 21, 2010)http://www.gih.org/usr_doc/Public_Health_Improvement_Plan_Caring_for_Colorado_June_2010.pdf.

61. Mike Mitka, “Medicare Head Donald M. Berwick, MD, Takes on Mission of Health System Reform,”Journal of the American Medical Association, November 1, 2010, http://jama.ama-assn.org/cgi/content/full/jama.2010.1662v1.

62. About IHI, Institute of Healthcare Improvement, http://www.ihi.org/ihi/about.63. Berwick, Op.Cit.64. Polly Hoppin, Molly Jacobs and Laurie Stillman, “Investing in Best Practices for Asthma, A Business

Case” (Boston: Asthma Regional Council of New England, 2010) , p. 3,http://asthmaregionalcouncil.org/uploads/Asthma%20Management/Investing%20in%20Best%20Practices%20fo%20Asthma-A%20Business%20Case%20%20August%202010%20Update.pdf.

65. Op.Cit., p. 4.66. Op.Cit., p. 3.67. Health Impact Project, http://www.healthimpactproject.org/.68. Mitchell H. Katz, “Future of the Safety Net Under Health Reform,” Journal of the American Medical

Association, 2010; 304(6):679-680, http://jama.ama-assn.org/content/304/6/679.extract.69. Op.Cit.

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70. “Protecting Consumers, Encouraging Community Dialogue: The New Law’s Requirements for Non-profit Hospitals,” (Boston: Community Catalyst, 2010), http://www.communitycatalyst.org/doc_store/publications/Hospital_Accountability_Summary_National_Reform_Law.pdf.

71. Peter Morici, “The Bush Tax Cuts and deficit reduction nonsense,” Finfacts Ireland, December 5,2010, http://www.finfacts.ie/irishfinancenews/article_1021180.shtml.

72. Shirley S. Wang, “China Sees Challenge on Health System,” Wall Street Journal, September 24,2010, http://online.wsj.com/article/SB10001424052748704062804575509563952924410.html.

73. Alice Rivlin, “Health Reform: Last Call for Competitive Markets?” Up Front Blog September 7, 2010,http://www.brookings.edu/opinions/2010/0907_health_reform_markets_rivlin.aspx.

74. Op.Cit.75. Luis A. Ubiñas, comments at the Ford Foundation, June 15, 2010.76. Margaret O’Bryon, author interview, July 22, 2010.77. Lisa Ranghelli and Gita Gulati Partee, Strengthening Democracy, Increasing Opportunities: Impacts of

Advocacy, Organizing and Civic Engagement in the Northwest Region. (Washington, D.C.: TheNational Committee for Responsive Philanthropy, September 2010),http://ncrp.org/files/publications/gcip-nw_report_low_res.pdf. For additional resources on advocacyand organizing, please see: http://ncrp.org/campaigns-research-policy/communities/gcip/gcip-resources.

78. Diane Lewis and Margaret O’Bryon, A Conversation on Health Justice (Washington, D.C.: ConsumerHealth Foundation, 2009).

79. “Structural Racism/Racialization,” Kirwan Institute, http://kirwaninstitute.org/research/structural-racism.php.

80. http://www.healthypeople.gov/2010/Document/tableofcontents.htm#under.81. For our purposes, “marginalized communities” includes 11 of the special population groups tracked

by the Foundation Center as possible beneficiaries of a foundation grant: economically disadvan-taged persons; racial or ethnic minorities; women and girls; people with HIV/AIDS; people with dis-abilities; aging, elderly, and senior citizens; immigrants and refugees; crime and abuse victims;offenders and ex-offenders; single parents; and LGTBQ citizens. See Niki Jagpal, Criteria forPhilanthropy at Its Best: Benchmarks to Assess and Enhance Grantmaker Impact (Washington, D.C.:National Committee for Responsive Philanthropy, 2009), p. 107-114.

82. The foundations identified as family foundations are large independent funders who also describethemselves as family foundations when providing their data to the Foundation Center. A total of 5 ofthe 22 exemplars identify themselves as a family foundation – the David and Lucile PackardFoundation , Richard and Rhoda Goldman Fund, The Nathan Cummings Foundation, The John MerckFund, The Educational Foundation of America. (Source: Foundation Center).

83. Definition of health conversion foundation from the Foundation Center: “In the past several decades,conversions of traditional nonprofit hospitals and health organizations to for-profit enterprises havehad a substantial impact on the field of health philanthropy. Since Federal law requires that proceedsfrom the sale of assets of tax-exempt entities be directed towards charitable purposes, one result ofthese conversions has been the creation of a number of new foundations, commonly referred to as‘new health foundations’ or ‘health conversion foundations.’ Since 1973, when the first health con-version foundation was established, nearly 200 other foundations of this type have been created.While the majority of health conversion foundations were established during the 1980s and 90s, theirnumbers continue to grow as more and more hospitals and health organizations make the transitionto for-profit status. While most health conversion foundations are dedicated to increasing access tohealth care, they typically have adopted a broad definition of health and sometimes support muchwider community purposes. As a result, these foundations have rapidly become a major source offunding not just for nonprofit health organizations, but for broader community-based organizations aswell.” From “Knowledge Base,” Grant Space,http://foundationcenter.org/getstarted/faqs/html/health_conv.html.

84. Bradford H. Gray and Mark Schlesinger, “Charitable Expectations of Nonprofit Hospitals: Lessonsfrom Maryland,”Health Affairs, 2009, 28: no.5, w809 – w821.

85. Robert Murray, “All Payer Bundled Payment Strategies, A Roadmap to Accountable Care OrganizationDevelopment and Quality Improvement,” Institute for Healthcare Improvement Executive QualityLeaders Network, October 8, 2010.

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NCRP STAFFMeredith Brodbeck COMMUNICATIONS ASSOCIATE

Samantha Davis FIELD ASSISTANT

Sean Dobson FIELD DIRECTOR

Aaron Dorfman EXECUTIVE DIRECTOR

Kevin Faria DEVELOPMENT DIRECTOR

Niki Jagpal RESEARCH & POLICY DIRECTOR

Kevin Laskowski RESEARCH & POLICY ASSOCIATE

Anna Kristina (“Yna”) C. Moore COMMUNICATIONS DIRECTOR

Lisa Ranghelli DIRECTOR, GRANTMAKING FOR COMMUNITY IMPACT PROJECT

Christine Reeves FIELD ASSOCIATE

Beverley Samuda-Wylder SENIOR ADMINISTRATIVE ASSOCIATE

BOARD OF DIRECTORS

EXECUTIVE COMMITTEEDiane Feeney (CHAIR) FRENCH AMERICAN CHARITABLE TRUST

Dave Beckwith (VICE CHAIR) NEEDMOR FUND

Cynthia Guyer (SECRETARY) INDEPENDENT CONSULTANT

Gary Snyder (TREASURER) NONPROFIT IMPERATIVE

Sherece Y. West (AT-LARGE) WINTHROP ROCKEFELLER FOUNDATION

DIRECTORSRobert Edgar COMMON CAUSE

Pablo Eisenberg PUBLIC POLICY INSTITUTE, GEORGETOWN UNIVERSITY

Marjorie Fine LINCHPIN CAMPAIGN, CENTER FOR COMMUNITY CHANGE

Ana Garcia-Ashley GAMALIEL FOUNDATION

Judy Hatcher ENVIRONMENTAL SUPPORT CENTER

Priscilla Hung GRASSROOTS INSTITUTE FOR FUNDRAISING TRAINING

Gara LaMarche THE ATLANTIC PHILANTHROPIES

Joy Persall MINNESOTA INDIAN WOMEN’S RESOURCE CENTER

Cynthia Renfro MARGUERITE CASEY FOUNDATION

Russell Roybal NATIONAL GAY AND LESBIAN TASK FORCE

William Schulz UNITARIAN UNIVERSALIST SERVICE COMMITTEE

Gerald L. Taylor INDUSTRIAL AREAS FOUNDATION

PAST BOARD CHAIRSPaul Castro JEWISH FAMILY SERVICE OF LOS ANGELES

John Echohawk NATIVE AMERICAN RIGHTS FUND

Pablo Eisenberg PUBLIC POLICY INSTITUTE, GEORGETOWN UNIVERSITY

David R. Jones COMMUNITY SERVICE SOCIETY OF NEW YORK

Terry Odendahl GLOBAL GREENGRANTS FUND

Organization affiliation for identification purposes only.

“This report presents an exciting vision for health philanthropy grounded in values of equity,

racial justice and opportunity. It tells a powerful story of how foundations across the country are

actively involved in deep and long-term work to change systems at the local level, using all of

the tools at their disposal. And, most importantly, it presents a clear pathway for all of us in all

of our communities to join this movement.”

—Margaret O’Bryon, Consumer Health Foundation

“NCRP’s report provides a blueprint with clear direction on what the philanthropic community

can do to ensure that health equity is realized. NCRP recognizes the necessity and urgency of

bringing marginalized communities to the decision-making table by building a platform for

advocacy and civic engagement that operates at the national, state and local levels.”

—Jennifer Ng’andu, National Council of La Raza

“NCRP’s new report describes concretely how its principles for effective philanthropy can be

operationalized to promote transformational change. At this critical time created by passage

of health reform, it points the way for bold action by health funders to reduce health inequali-

ties and build a high-performing health system.”

—Lauren LeRoy, Grantmakers In Health

A Philanthropy at Its Best® Report

TOWARDS TRANSFORMATIVE CHANGE IN HEALTH CAREHigh Impact Strategies for Philanthropy© April 2011, National Committee for Responsive Philanthropy

Despite billions of philanthropic grant dollars each year being dedicated to health issues, Americansrely on an inequitable health care system that is fragmented, inefficient and costly. The consequencesof allowing this ineffective system to perpetuate have led to where health outcomes are determinedby social factors such as geography, wealth, race and gender. Can health philanthropy be moreeffective at deploying its limited resources to address this crucial but broken system? TowardsTransformative Change in Health Care offers two high impact strategies for grantmakers to moreeffectively achieve their missions and help address disparate health outcomes resulting from unequalopportunities. It recommends focusing on the unique needs and circumstances of all communities,especially those that remain underserved, and funding heavily advocacy, community organizing andcivic engagement for systemic reform.

This is the second in a series of reports from the National Committee for Responsive Philanthropy(NCRP) that invites grantmakers focused on specific issues to rethink their funding strategies togenerate the greatest impact. A report on education philanthropy was published in October 2010.Future reports will be for funders concerned about the environment and the arts.

For information or copies of this report, or to join NCRP, please contact us at:1331 H Street NW, Suite 200 • Washington D.C. 20005

Phone 202.387.9177 • Fax 202.332.5084 • E-mail: [email protected] • Web: www.ncrp.org

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