A new book examines the strategies and impact of The Robert Wood Johnson Foundation’s grant programs.
By: David Ludlum
Can The Robert Wood Johnson Foundation help fix the nation’s health insurance system, which fails to provide coverage for 40 million Americans including 10 million children?
The question seems worth posing since RWJF was number one in health care spending by U.S. foundations in 2001, the most recent year for which figures are available from the Foundation Center, a New York-based nonprofit supporting philanthropic organizations.
If the foundation can make an impact, some clues as to how it might do so can be found in an analysis of its past work, published this month in "The Robert Wood Johnson Foundation Anthology: To Improve Health & Health Care" (Jossey-Bass, 2003). The new book examines the foundation’s programs and other initiatives in 10 fields, and draws conclusions about what approaches to grant-making have worked and which ones haven’t.
The book is the seventh installment in a series about the projects funded by the foundation, edited by San Francisco-based consultant Stephen Isaacs and James Knickman, RWJF’s vice president for research and evaluation. Case studies on RWJF programs were written by independent journalists."We tell our authors to feel free to be as critical as they feel is justified," Mr. Isaacs said.
The Robert Wood Johnson Foundation, located in Princeton, is the fifth largest foundation in the United States (the largest U.S. foundation is the one created by the founder of Microsoft, the Bill and Melinda Gates Foundation, which had $24 billion in assets at the end of 2002).
Created in 1972 by a former head of Johnson & Johnson, RWJF’s endowment stood at $8 billion at the end of 2002, and during that year it awarded grants and contracts valued at $360 million.
In their overview, Mr. Isaacs and Mr. Knickman identify 11 approaches to grant-making that they believe have furthered the foundation’s mission to improve the health and healthcare of Americans. (See sidebar, "Successful approaches," at right).
Among the successful initiatives they cite are efforts to get people to stop smoking, to improve "end-of-life" care for the terminally ill and to expand the use of nurse practitioners and physician assistants.
Among the foundation’s less successful initiatives the editors cite is reform of the nation’s health insurance system.
In the anti-smoking drive, Mr. Isaacs and Mr. Knickman credit several approaches: getting involved as the issue was gaining momentum; focusing on one small but significant piece of the problem smoking by children; and funding smoking-related research, discussions, communication, demonstrations (experiments), training, standards and advocacy.
It’s not possible to quantify the foundation’s achievements, Mr. Isaacs acknowledges, but significant investments in key researchers and advocacy groups, such as the Center for Tobacco Free Kids, have put a dent in the problem. "This investment speeded up the process or made it possible for the process to happen," Mr. Isaacs said.
The authors credit the same approaches for the foundation’s success in improving end-of-life care, along with another approach learning from mistakes.
RWJF has been responsible for the addition of end-of-life material to a wide variety of medical textbooks, the emergence of conferences and professional associations devoted to the subject and the establishment of pain-management practices in many hospitals.
Expanded use of nurse practitioners and physician assistants arose in part from replicating trials across the country. Since the 1970s, however, it has become much more difficult to do this, Mr. Isaacs said. Then the foundation could launch five experimental projects and expect the federal government to build on successes. Since the 1980s, however, it has passed such responsibilities on to the states, which lack the necessary funds, he said. As a result, foundations have to make a larger commitment, in time and money, to each project.
Unfortunately, the same tactics have not been as successful in making affordable, quality health care available to more people, a goal of the foundation since its inception. Mr. Isaacs and Mr. Knickman point to some differences between that problem and the issue of smoking: smoking is widely recognized a healthcare issue, offers a convenient villain in big tobacco companies and entails a relatively simple solution quitting.
With health insurance, there is less public concern, no agreed-upon bad guy and much more political divisiveness.
The foundation has succeeded in raising awareness about the uninsured, said Lauren LeRoy, president and CEO of Grantmakers in Health, a nonprofit organization based in Washington, D.C., that encourages collaboration among foundations. It also has had a significant impact in countering substance abuse and, more recently, promoting efforts to prevent illness and encourage healthy lifestyles in order to avoid the need for medical care, she said.
But significant reforms to the health insurance system still seem far from reach, in part because it is such a complicated issue about which there is little public consensus, said Mr. Knickman. "We need to tackle it piece by piece," he said. "It doesn’t look like the country is ready for a grand solution."