Cite this article as: L L Prina Assuring access to health care: the Robert Wood Johnson Foundation strategy Health Affairs 11, no.2 (1992):198-201 doi: 10.1377/hlthaff.11.2.198
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/11/2/19 8.citation
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At the Intersection of Health, Health Care and Policy
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
198 HEALTH AFFAIRS | Summer 1992 III. PROFILE
by Lee L. Prina Improving access to basic health care is the linchpin in The Robert Wood Johnson Foundation’s (RWJF’s) grant-making strategy for the 1990s. This goal of assuring access to care for all Americans is one of three new program goals set forth last year by the f o u n d a ti o n ’ s p r e s id en t, Steve n A. Schroeder. To address the problem, the foundation has decided to zero in on what it sees as the three barriers to access: financing, supply and distribution, and organizational/ sociocultural factors. Schroeder’s objectives for the foundation regarding access are ambitious. “The first thing I’d like to see accomplished is that [access] become a major policy issue,” he said. To do so, he said, necessary ingredients are accurate data and well-focused programs. “More fundamentally, we have to try to help the nation come to grips [with the fact] that this is a problem that we can do something about,” he explained in an interview at his Princeton, New Jersey, office. The foundation’s leadership role is important, Schroeder believes. RWJF plans to focus on the uninsured, the underinsured, and the inadequacies of the public and private health insurance system. He wants RWJF to look at such national trends as how well Americans are achieving access to basic health care. RWJF Vice-President Ruby Heam, who has been on staff for sixteen years, chairs the foundation’s Access Goal Development Work Group. She said that this internal panel helps with program strategy and development and defined the main barriers to access that the foundation is addressing. Lee-Lee Prina is an assistant editor of Health Affairs. She oversees the GrantWatch section and writes the Grants and Outcomes portion each issue.
Barriers To Access Financing. Paying for the care of uninsured and underinsured persons is the first barrier being tackled. In 1991, RWJF’s board authorized $25.5 million for a state health care financing reform initiative, which received thirty-five proposals. The fifteen states awarded funding will develop and test ways to expand access and control costs. These reform efforts might be instructive in the broader national policy debate, according to Alan Cohen, RWJF vice-president, who has been at the foundation for eight years. RWJF also will fund technical assistance as part of the program. Schroeder said that in the future, RWJF will look at programs to help “besieged inner-city institutions.” A recent grant to the United Hospital Fund is “looking at preventable hospitalizations where early access can make a difference,” he said. Supply and distribution. The supply and distribution barrier includes shortages and uneven distribution of generalist personnel, facilities–especially in inner cities and rural areas–and technology. “I feel that the [lack of generalists] is an unrecognized or underrecognized health policy problem,” Schroeder said. “It is frustrating to me to read in the debates about health care reform that people assume that the health care system is going to stay as it is–we’re just going to change who pays and not who gets paid, and how much. The health care system really doesn’t match what the country needs.” (See “Physician Supply and the U.S. Medical Marketplace,” the GrantWatch essay by Schroeder, in the Spring 1992 issue of Health Affairs.) To address this barrier, RWJF has instituted the Generalist Physician Initiative, which aims to stimulate medical schools to increase the supply of generalists. This program, which requires local matching funds, was authorized in 1991 at up to $32.7 million over seven and a half years. Getting medical schools to change their specialty orientation will be a challenge, according to Cohen. He believes that public medical
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 23, 2016 by HW Team
Assuring Access To Health Care: The Robert Wood Johnson Foundation Strategy
GR ANTWATC H 1 9 9 D.C., ad dressed by Surgeon General Antonia Novello and former First Lady Rosalyn Carter. The program will help track down children who have not been immunized against childhood diseases. Twenty planning grants will be awarded; priority will be given to proposals that look at broader prevention issues, Hearn said.
Access Through The Years Access to care has been a pr iority throughout RWJF’s twenty-year history. The thrust in the 1970s was to improve access to primary care for the rural and inner-city poor. In the early 1970s, foundation staff– like many other health watchers– believed that “national health insurance was just around the corner,” Schroeder said. RWJF started funding the training of nurse practitioners, physician assistants, and generalist physicians. “My guess is that those programs worked in their own way, but they were insufficient against all the other disincentives for health professionals to get into generalist careers,” he said. In the late 1970s and early 1980s, the foundation sponsored three important access surveys in cooperation with the University of Chicago. “The data clearly showed major improvements in access,” Schroeder said, attributing some of that to Medicare and Medicaid. “It’s fashionable to criticize Medicaid, but in some ways it has been a very strong program,” he commented. In the early 1980s, RWJF changed its emphasis, to target underserved population groups. In the late 1980s, access was not explicitly mentioned in the foundation’s goals but was “understood and implicit” in its express concern for vulnerable populations and key health problems, according to Cohen. During that decade, RWJF’s national demonstration, the Health Care for the Uninsured Program, targeted insurance coverage primarily for people employed by small businesses. (For discussion of this program, see W. David Helms, Anne K. Gauthier, and Daniel M. Campion, “Mending the Flaws in the Small-Group Market,” pages 7-27; and Catherine G. McLaughlin and Wendy K. Zellers, “The Shortcomings
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 23, 2016 by HW Team
schools may be more interested than private ones in participating, because of their historical orientation toward primary care. Approximately 300 people representing 110 institutions attended the RWJF applicants’ workshop in February 1992 on the generalist initiative. Interested applicants came–at their own expense– to ask questions about the initiative and the request for proposals, according to Schroeder. The initiative “may stimulate medical schools to rethink their training mission,” he added. RWJF is asking every school funded under the program to show an improvement over its current percentage of generalist graduates. At their April 1992 meeting, the foundation’s trustees authorized $14.4 million over four years for a medical school faculty scholars program. The program’s aim is “to increase senior generalist physician faculty [who could serve] as role models,” Hearn said in a telephone interview. The program hopes to help these facu lty members achieve seniority and visibility and become leaders in the field of general medicine. Practice Sights: State Primary Care Development Strategies is an initiative, “geographically targeted” at medically underserved areas of the United States, to alleviate the distribution problem by getting physicians and other health care personnel into these areas and by improving the environment for primary care practice. The initiative was authorized for $16.5 million in 1991 and will tackle both recruitment and retention issues. Organizational/sociocultural barriers. The hours care is available, beliefs, attitudes, and languages spoken by both patients and providers all can be barriers to care. RWJF currently has no broad initiatives to attack these problems, although it is considering various individual grants in this area. Less is known about this set of barriers. The foundation hopes to point out areas where more research is needed, identify successful projects and disseminate that information, and test new approaches. A related $9.3 million program, All Kids Count, was launched in December 1991 with a press conference in Washington,
200 HEALTH AFFAIRS | Summer 1992 whole.” The earlier method RWJF used in trying to influence public policy, which was “let’s just put the data out there and assume that people will make the right choice, may not be effective as health becomes more of a political issue,” Schroeder noted. Politics’ link with policy was not so apparent years ago. The third lesson is that today “the issues of equity and solidarity” apparent in other countries are not as strong in the United States. “There seems to be a fairly. . . prevalent point of view, hacked up by voting patterns, that people are not as charitable as they might be,” Schroeder said. Evaluations and partnerships. When asked how RWJF is different from other foundations in its approach to access, Hearn pointed to its emphasis on independently funded evaluations, especially of the multisite projects. “RWJF is committed to knowing whether its programs are making a difference. Steve Schroeder wants RWJF to hold itself accountable,” she said. Schroeder explained the process: “We’re going to monitor at two levels. One is at the micro level, where we’re giving grants: Did the grants themselves make a difference? We’re also going to try to monitor [trends] at the national level. . , . If things get better, can the foundation take credit, and if they get worse, is it the foundation’s fault? Of course, we can never make that kind of link. Frankly, what I’m concerned about is making sure that our programs are relevant to the needs of the population.” RWJF’s Dianne Barker is working on the system to monitor national trends in each of the foundation’s goal areas, plus cost containment. The Center for Health Economics Research in Waltham, Massachusetts, received a contract in January 1992 to do annual indicator profiles on access and health care costs, to he presented using graphics and text. Beyond evaluations, RWJF takes a multipronged approach to access issues, said Hearn. RWJF collaborates with other foundations and the government, and it initiates programs. To help attain its access goal, RWJF is exploring how to “package a set of interventions,” including training, conven-
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 23, 2016 by HW Team
of Voluntarism in the Small-Group Insurance Market,” pages 28– 40, in this volume of Health Affairs.) When Schroeder became president in July 1990, he emphatically restated the access goal: the assurance of basic health care for all Americans. “We have recast our strategy from focusing on specific recipient groups to focusing more on issues, so that it may seem like we’re doing more [now] with access,” he commented. RWJF now takes more of a systemic look at the problem, hut no huge shift in emphasis has occurred, he said. RWJF funding strategies for the 1990s will include fewer service demonstration programs. In the 1980s, the philosophy was “let’s help communities develop model projects and assume that someone else will come in and help them perpetuate those projects,” Schroeder said. “I think in the 1990s it’s unlikely that new money is going to he coming around to help model projects,” mostly because of fiscal constraints at all levels of government. RWJF had to change with the times, he said. Lessons learned. As the problems facing the health care system have grown more perplexing, it takes longer to make headway toward improvements. To meet this concern, RWJF is trying to he more flexible in determining the time allotted for new programs. In tailoring the design to individual project needs, some time frames are longer than were typical of past efforts, and some are shorter. “Getting the kind of broad-based political support needed to achieve universal access is going to be difficult,” Schroeder commented. America is very different from many other countries, he added; its citizens don’t trust their government. “How to try to reconcile the need for universal coverage with a reluctance to have government in control of it is a real challenge for us as citizens," he said. The second lesson Schroeder mentioned was that, as health has become a big business, “each advocacy group has dug in its heels pressing for its own special interest, and often there’s not been a common denominator. These groups haven’t asked what would he the best for the nation as a
GRANTWATCH 2 01 ing of meetings, research, and communications. The “only constraints are creativity,” as the RWJF board has given “a green light in the access area,” Hearn said. RWJF is paying more attention to the general public’s role in mobilizing the policy process and is attempting to keep the public wellinformed about access. A variety of communications projects are already being funded.
The Inherent Risks Schroeder and Cohen agreed that there are risks in the current access programs. Indeed, “There are risks in any program that tries to break new ground,” Schroeder said. “But I believe that the bigger risk for a foundation is not to take risks– to do nothing or to he on the margin of a problem.” As an example, if national health care reform arrives, it could make irrelevant the lessons learned from the RWJF state health care financing initiative. Or, the U.S. economy could worsen, or states’ programs could be so varied and idiosyncratic that it would he impossible to adopt them in other states. The unacceptable alternative for RWJF, however, would have been “to sit back and wait for these political and economic forces to play out,” Schroeder said. Inertia, ethnocentrism, and insensitivity among some people may work against RWJF’s current and future work to eliminate sociocultural barriers, Cohen said. The immunization program, however, is less risky, Schroeder said, because of widespread public recognition of this problem, brought about by some tragic recent outbreaks of preventable diseases. Also, the program makes economic sense: “It costs less to prevent measles than to treat it,” he said. Role In The Public Policy Debate While the foundation’s tax status prevents it from lobbying, Schroeder mentioned several public policy roles for the foundation: “We can try to make sure health stays a political issue in the public’s mind. We can help to provide some of the data and tested models for the debate. We can also bring
people together to talk about issues and talk about solutions.” He added, “We take this role very seriously, because RWJF is one of the few groups involved in health care policy reform now that doesn’t have a special ax to grind.”
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/11/2/19 8.citation
For Reprints, Links & http://content.healthaff Permissions : airs.org/1340_reprints. php Email Alertings :
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Not for commercial use or unauthorized distribution
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At the Intersection of Health, Health Care and Policy
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Not for commercial use or unauthorized distribution
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
198 HEALTH AFFAIRS | Summer 1992 III. PROFILE
by Lee L. Prina Improving access to basic health care is the linchpin in The Robert Wood Johnson Foundation’s (RWJF’s) grant-making strategy for the 1990s. This goal of assuring access to care for all Americans is one of three new program goals set forth last year by the f o u n d a ti o n ’ s p r e s id en t, Steve n A. Schroeder. To address the problem, the foundation has decided to zero in on what it sees as the three barriers to access: financing, supply and distribution, and organizational/ sociocultural factors. Schroeder’s objectives for the foundation regarding access are ambitious. “The first thing I’d like to see accomplished is that [access] become a major policy issue,” he said. To do so, he said, necessary ingredients are accurate data and well-focused programs. “More fundamentally, we have to try to help the nation come to grips [with the fact] that this is a problem that we can do something about,” he explained in an interview at his Princeton, New Jersey, office. The foundation’s leadership role is important, Schroeder believes. RWJF plans to focus on the uninsured, the underinsured, and the inadequacies of the public and private health insurance system. He wants RWJF to look at such national trends as how well Americans are achieving access to basic health care. RWJF Vice-President Ruby Heam, who has been on staff for sixteen years, chairs the foundation’s Access Goal Development Work Group. She said that this internal panel helps with program strategy and development and defined the main barriers to access that the foundation is addressing. Lee-Lee Prina is an assistant editor of Health Affairs. She oversees the GrantWatch section and writes the Grants and Outcomes portion each issue.
Barriers To Access Financing. Paying for the care of uninsured and underinsured persons is the first barrier being tackled. In 1991, RWJF’s board authorized $25.5 million for a state health care financing reform initiative, which received thirty-five proposals. The fifteen states awarded funding will develop and test ways to expand access and control costs. These reform efforts might be instructive in the broader national policy debate, according to Alan Cohen, RWJF vice-president, who has been at the foundation for eight years. RWJF also will fund technical assistance as part of the program. Schroeder said that in the future, RWJF will look at programs to help “besieged inner-city institutions.” A recent grant to the United Hospital Fund is “looking at preventable hospitalizations where early access can make a difference,” he said. Supply and distribution. The supply and distribution barrier includes shortages and uneven distribution of generalist personnel, facilities–especially in inner cities and rural areas–and technology. “I feel that the [lack of generalists] is an unrecognized or underrecognized health policy problem,” Schroeder said. “It is frustrating to me to read in the debates about health care reform that people assume that the health care system is going to stay as it is–we’re just going to change who pays and not who gets paid, and how much. The health care system really doesn’t match what the country needs.” (See “Physician Supply and the U.S. Medical Marketplace,” the GrantWatch essay by Schroeder, in the Spring 1992 issue of Health Affairs.) To address this barrier, RWJF has instituted the Generalist Physician Initiative, which aims to stimulate medical schools to increase the supply of generalists. This program, which requires local matching funds, was authorized in 1991 at up to $32.7 million over seven and a half years. Getting medical schools to change their specialty orientation will be a challenge, according to Cohen. He believes that public medical
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 23, 2016 by HW Team
Assuring Access To Health Care: The Robert Wood Johnson Foundation Strategy
GR ANTWATC H 1 9 9 D.C., ad dressed by Surgeon General Antonia Novello and former First Lady Rosalyn Carter. The program will help track down children who have not been immunized against childhood diseases. Twenty planning grants will be awarded; priority will be given to proposals that look at broader prevention issues, Hearn said.
Access Through The Years Access to care has been a pr iority throughout RWJF’s twenty-year history. The thrust in the 1970s was to improve access to primary care for the rural and inner-city poor. In the early 1970s, foundation staff– like many other health watchers– believed that “national health insurance was just around the corner,” Schroeder said. RWJF started funding the training of nurse practitioners, physician assistants, and generalist physicians. “My guess is that those programs worked in their own way, but they were insufficient against all the other disincentives for health professionals to get into generalist careers,” he said. In the late 1970s and early 1980s, the foundation sponsored three important access surveys in cooperation with the University of Chicago. “The data clearly showed major improvements in access,” Schroeder said, attributing some of that to Medicare and Medicaid. “It’s fashionable to criticize Medicaid, but in some ways it has been a very strong program,” he commented. In the early 1980s, RWJF changed its emphasis, to target underserved population groups. In the late 1980s, access was not explicitly mentioned in the foundation’s goals but was “understood and implicit” in its express concern for vulnerable populations and key health problems, according to Cohen. During that decade, RWJF’s national demonstration, the Health Care for the Uninsured Program, targeted insurance coverage primarily for people employed by small businesses. (For discussion of this program, see W. David Helms, Anne K. Gauthier, and Daniel M. Campion, “Mending the Flaws in the Small-Group Market,” pages 7-27; and Catherine G. McLaughlin and Wendy K. Zellers, “The Shortcomings
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 23, 2016 by HW Team
schools may be more interested than private ones in participating, because of their historical orientation toward primary care. Approximately 300 people representing 110 institutions attended the RWJF applicants’ workshop in February 1992 on the generalist initiative. Interested applicants came–at their own expense– to ask questions about the initiative and the request for proposals, according to Schroeder. The initiative “may stimulate medical schools to rethink their training mission,” he added. RWJF is asking every school funded under the program to show an improvement over its current percentage of generalist graduates. At their April 1992 meeting, the foundation’s trustees authorized $14.4 million over four years for a medical school faculty scholars program. The program’s aim is “to increase senior generalist physician faculty [who could serve] as role models,” Hearn said in a telephone interview. The program hopes to help these facu lty members achieve seniority and visibility and become leaders in the field of general medicine. Practice Sights: State Primary Care Development Strategies is an initiative, “geographically targeted” at medically underserved areas of the United States, to alleviate the distribution problem by getting physicians and other health care personnel into these areas and by improving the environment for primary care practice. The initiative was authorized for $16.5 million in 1991 and will tackle both recruitment and retention issues. Organizational/sociocultural barriers. The hours care is available, beliefs, attitudes, and languages spoken by both patients and providers all can be barriers to care. RWJF currently has no broad initiatives to attack these problems, although it is considering various individual grants in this area. Less is known about this set of barriers. The foundation hopes to point out areas where more research is needed, identify successful projects and disseminate that information, and test new approaches. A related $9.3 million program, All Kids Count, was launched in December 1991 with a press conference in Washington,
200 HEALTH AFFAIRS | Summer 1992 whole.” The earlier method RWJF used in trying to influence public policy, which was “let’s just put the data out there and assume that people will make the right choice, may not be effective as health becomes more of a political issue,” Schroeder noted. Politics’ link with policy was not so apparent years ago. The third lesson is that today “the issues of equity and solidarity” apparent in other countries are not as strong in the United States. “There seems to be a fairly. . . prevalent point of view, hacked up by voting patterns, that people are not as charitable as they might be,” Schroeder said. Evaluations and partnerships. When asked how RWJF is different from other foundations in its approach to access, Hearn pointed to its emphasis on independently funded evaluations, especially of the multisite projects. “RWJF is committed to knowing whether its programs are making a difference. Steve Schroeder wants RWJF to hold itself accountable,” she said. Schroeder explained the process: “We’re going to monitor at two levels. One is at the micro level, where we’re giving grants: Did the grants themselves make a difference? We’re also going to try to monitor [trends] at the national level. . , . If things get better, can the foundation take credit, and if they get worse, is it the foundation’s fault? Of course, we can never make that kind of link. Frankly, what I’m concerned about is making sure that our programs are relevant to the needs of the population.” RWJF’s Dianne Barker is working on the system to monitor national trends in each of the foundation’s goal areas, plus cost containment. The Center for Health Economics Research in Waltham, Massachusetts, received a contract in January 1992 to do annual indicator profiles on access and health care costs, to he presented using graphics and text. Beyond evaluations, RWJF takes a multipronged approach to access issues, said Hearn. RWJF collaborates with other foundations and the government, and it initiates programs. To help attain its access goal, RWJF is exploring how to “package a set of interventions,” including training, conven-
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 23, 2016 by HW Team
of Voluntarism in the Small-Group Insurance Market,” pages 28– 40, in this volume of Health Affairs.) When Schroeder became president in July 1990, he emphatically restated the access goal: the assurance of basic health care for all Americans. “We have recast our strategy from focusing on specific recipient groups to focusing more on issues, so that it may seem like we’re doing more [now] with access,” he commented. RWJF now takes more of a systemic look at the problem, hut no huge shift in emphasis has occurred, he said. RWJF funding strategies for the 1990s will include fewer service demonstration programs. In the 1980s, the philosophy was “let’s help communities develop model projects and assume that someone else will come in and help them perpetuate those projects,” Schroeder said. “I think in the 1990s it’s unlikely that new money is going to he coming around to help model projects,” mostly because of fiscal constraints at all levels of government. RWJF had to change with the times, he said. Lessons learned. As the problems facing the health care system have grown more perplexing, it takes longer to make headway toward improvements. To meet this concern, RWJF is trying to he more flexible in determining the time allotted for new programs. In tailoring the design to individual project needs, some time frames are longer than were typical of past efforts, and some are shorter. “Getting the kind of broad-based political support needed to achieve universal access is going to be difficult,” Schroeder commented. America is very different from many other countries, he added; its citizens don’t trust their government. “How to try to reconcile the need for universal coverage with a reluctance to have government in control of it is a real challenge for us as citizens," he said. The second lesson Schroeder mentioned was that, as health has become a big business, “each advocacy group has dug in its heels pressing for its own special interest, and often there’s not been a common denominator. These groups haven’t asked what would he the best for the nation as a
GRANTWATCH 2 01 ing of meetings, research, and communications. The “only constraints are creativity,” as the RWJF board has given “a green light in the access area,” Hearn said. RWJF is paying more attention to the general public’s role in mobilizing the policy process and is attempting to keep the public wellinformed about access. A variety of communications projects are already being funded.
The Inherent Risks Schroeder and Cohen agreed that there are risks in the current access programs. Indeed, “There are risks in any program that tries to break new ground,” Schroeder said. “But I believe that the bigger risk for a foundation is not to take risks– to do nothing or to he on the margin of a problem.” As an example, if national health care reform arrives, it could make irrelevant the lessons learned from the RWJF state health care financing initiative. Or, the U.S. economy could worsen, or states’ programs could be so varied and idiosyncratic that it would he impossible to adopt them in other states. The unacceptable alternative for RWJF, however, would have been “to sit back and wait for these political and economic forces to play out,” Schroeder said. Inertia, ethnocentrism, and insensitivity among some people may work against RWJF’s current and future work to eliminate sociocultural barriers, Cohen said. The immunization program, however, is less risky, Schroeder said, because of widespread public recognition of this problem, brought about by some tragic recent outbreaks of preventable diseases. Also, the program makes economic sense: “It costs less to prevent measles than to treat it,” he said. Role In The Public Policy Debate While the foundation’s tax status prevents it from lobbying, Schroeder mentioned several public policy roles for the foundation: “We can try to make sure health stays a political issue in the public’s mind. We can help to provide some of the data and tested models for the debate. We can also bring
people together to talk about issues and talk about solutions.” He added, “We take this role very seriously, because RWJF is one of the few groups involved in health care policy reform now that doesn’t have a special ax to grind.”
