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INTERVIEWAddressing Both Health And Health Care: An Interview With Steven A. Schroeder
John Iglehart: The Robert Wood Johnson Foundation is a giant among private philanthropies in terms of its resources and the authority that those resources command. What is the value of those financial resources today compared with when you arrived at the foundation in 1990? Steven Schroeder: When I arrived, the foundation held assets of $2.6 billion. By early 2002 that total had grown to $9.3 billion; today it’s around $8 billion. Each year, by IRS code, we must pay out, as a minimum, 5 percent of our average asset value, so we will expend about $400 million this year, down from about $450 million in 2001. Iglehart: How has that growth changed RWJ? Schroeder: I have been fortunate to be here at a time of rapid growth. As our grant making has expanded, so has our staff. We have more than doubled our available space through the construction of a new building. And we’ve mothballed some of that space in case we need to expand further. In the programmatic sense, our growth has allowed us to vastly expand the health part of our mission—that part that addresses the behavioral and social causes of poor health. Our mission is to improve health and health care for the American people. But, in our first eighteen years, RWJ was pretty much a health care foundation, based largely on the medical model. The public health component was underdeveloped. During the rapid growth of the 1990s we were able to greatly expand our public health activities while keeping our health care grant making relatively stable. In 1999 we reorganized the foundation into two overlapping groups, one dedicated to health, the other to health care, each headed by a senior vice-president. This would have been a much more difficult task had we not enjoyed such tremendous growth in our assets. Today, our grant making is pretty much fifty-fifty between health and health care. Previously, it was ninety-five–five in favor of health care. Iglehart: What persuaded you and RWJ’s board to reorder its priorities in such a profound fashion? Schroeder: We perceived opportunities that were not being addressed by philanthropy or other funders. First of all, in 1991 we established reducing the harm from substance abuse as one of the foundation’s goals. As its chief salesman, I can tell you, that was not an easy sell, but it was one that the staff and the board came to appreciate. As we saw the impact of RWJ’s efforts to fight substance abuse, it whetted our appetite to expand our health goals. We also recognized that very few other foundations were granting large sums to address public health priorities. By the late 1990s we decided as a foundation that equalizing our investments between health and health care could potentially pay rich dividends. This led to the reorganization and the current approximate fifty-fifty split of grant making.
Iglehart: What do you regard as the foundation’s single most important achievement during your stewardship? Schroeder: I believe it was the establishment of health as an equal partner with health care. When you look at the determinants of health and what it will take to make our country healthier, we could have an ICU on every block and still not get there. Yet most foundation and government funding is targeted at providing medical care rather than advancing the public’s health in more consequential ways. Iglehart: Is promoting the public’s health a little bit like swimming uphill in a society that attaches such a high value to medical care and the expansion of health insurance? Schroeder: Oh, it is, but I think a double standard underlies even your basic question. You could have asked about the futility, as some perceive it, of expanding health insurance coverage in the United States. And so we have this double standard, that even seemingly quixotic quests, like trying to reduce the number of uninsured, somehow seem more orthodox, more urgent, than trying to get people to stop smoking. In fact, there’s been a lot more progress on smoking in the past thirty years than there has been in covering the uninsured. So I don’t think it’s necessarily more uphill in health than in health care. But it’s harder, because there’s stigma attached to it. And there’s a sense among some that if a large portion of the nation’s population is obese or sedentary, drinks or smokes too much, or uses illegal drugs, that’s their own fault or their own business.
Iglehart: Elaborate, if you will, on the foundation’s achievements in promoting health. Where has RWJ made its greatest strides? Schroeder: I think we’ve helped to make a field safer and more respectable. We’ve been able to contribute voices and money and data to a field that was not as developed as it should be. It’s not that we were the first ones there. Far from it. There have been pioneers working in this field for a long time. But I think when a big foundation comes in and declares, this is an important area and we’re going to stay with it, it sends a strong signal. It is hard to separate what RWJ has done on its own in smoking cessation and the contribution of tobacco lawsuits that have been pursued through the courts. But look at the position of the tobacco industry today compared with 1990. The industry is not as invulnerable as it once seemed. Fewer people are smoking, with the important exception of college students. There are more and more public places and private gathering spots—restaurants, for instance—where smoking has been restricted through state and local actions. The climate in favor of raising state and local tobacco taxes is vastly different today than a decade ago. And the dangers of smoking are better understood. It’s not that we’ve won that battle, but great strides have been made and can be documented. In excessive drinking and illegal drug use, there is a greater understanding that treatment is a very important component of recovery. And again, we often get a double-standard question there. Well, don’t many people relapse? Yes, of course. But is it worth treating pancreatic cancer, which has a 5 percent survival rate, at most? Yes. So the odds of successfully treating drug abuse or alcoholism are actually better than in many of the serious illnesses that society, without question, wants us to treat.
Iglehart: Let me turn to RWJ’s initiative around health insurance and its ambitious efforts to expand coverage. The foundation has done a number of innovative things, including the "strange bedfellows" activity that linked the commercial health insurance industry with Families USA, a consumer activist organization [see Health Affairs, Jan/Feb 01, 40–48]; the encouragement of local newspaper editorials promoting the idea that broadened coverage is good for society; and so forth. In your opinion, how successful has this effort been? Schroeder: We consistently debate that very question. One side says, "This is a problem that’s been going on for almost forty years, so why pour good money after bad if we are unlikely to achieve universal coverage or anything close to that? Let’s just accept that we’re going to ration care to the poor and use money in a more worthwhile way." The other side, which I am on, says, "Wait a minute. What could be more central to the values and moral character of a country than the fact that tens of millions of its citizens don’t have access to basic health care because they don’t have insurance? And what would it mean if the nation’s largest health philanthropy threw up its hands and abandoned this quest?" RWJ is siding with this latter position, with the realization that it is probably the most uphill of any of the things that we’ve been working on. There is reason for optimism that we’re not just tilting at windmills. For example, our work in the Covering Kids Initiative: There are now two million fewer uninsured children partly as a result of that national effort, which is tied directly to the State Children’s Health Insurance Program [SCHIP]. Nationally, 88 percent of all children have health insurance now—the highest percentage in fifteen years.
Iglehart: Like David Rogers, the first president of the foundation, you are regarded as a champion of primary care and its inherent value to any health care system. Over the years RWJ has invested a lot of its resources in the promotion of primary care. What has been the foundation’s return on this investment, and what’s your view on the state of primary care today? Is it in decline, is it ascending—where does it stand? Schroeder: It’s been on a roller coaster. In the early 1990s there was hope that managed care could get the health care system to have its cake and eat it, too—that is, to improve quality and access and keep costs down. Primary care physicians and other professionals like nurse practitioners were seen as linchpins to that strategy. As you know, there was a revolt, a backlash, against the managed care strategy. For that reason and others, there has been a decline in the prestige and job satisfaction of primary care physicians. I sense a swing of the pendulum toward more of an elevation of interest in specialism, and less money, unfortunately, for primary care. But I see it as a very unstable situation. I do believe that primary care health professionals are going to be critical if the U.S. health care system is ever to realize its full potential. But, in the short term, primary care is in for some rough sledding. Iglehart: What would you cite as measures of the decline of primary care? Schroeder: One is student interest in the primary care specialties, as measured by the rate at which they enter residency training programs. In particular, family medicine has fallen off, but so have internal medicine and pediatrics. In 2002 only 47 percent of family practice residency positions available through the national matching service were filled by graduates of U.S. medical schools, compared with almost 73 percent only six years ago. Two, job satisfaction surveys: I think all health professionals are less satisfied than they were, but this feeling is most pronounced in primary care. Three, the differential in salaries between primary care and specialist physicians, already large, is growing as the incomes of technology-intensive doctors are on the increase again.
Iglehart: Both of your sons are physicians. What is their view of medicine’s future? Schroeder: One has become a cardiologist, the other a pediatrician. They are both enthusiastic about medicine, but many of their role models are discouraged about the profession. They see colleagues with huge student debts, and they worry about the environment in which they will be allowed to practice. If physicians and nurses, who are central to the operation of a system, however care is financed, are dissatisfied and feel undervalued, I grieve for that system because that is a system in trouble. Iglehart: Richard Cooper, writing in Health Affairs [Jan/Feb 02], asserted that based on a model he and colleagues developed, the United States will soon face a shortage of physicians, particularly specialists. What’s your view of Cooper’s conclusion? Schroeder: As I understand his work, Cooper bases his conclusion on trends in the overall economy over the past seventy years and future projections of it. He finds that the wealthier the populace, the more they see their disposable income or someone else’s disposable income being used to purchase health care. And, what they want to purchase is more specialized health care, because that’s where the technology’s going. I think, all other things being equal, he may be right, but I’m not sure we can say all things are going to be equal. I see the U.S. on a collision course between available resources and increased demand for health services. The baby boomers are nearing retirement and are less willing to accept, as did so many of their parents, the inevitable physical infirmities that come with aging. So, many will want new joints, cochlear implants, and Viagra, but they’ll want someone else to pay for these items. What worries me about the "let’s let specialists take over the health care system" point of view is that specialists tend to want to use their technology for many valid reasons. But it’s a staggeringly expensive way to run a health care system. And it’s an experiment that no other country has attempted.
Iglehart: It has been seven or eight years now since the Republicans harshly criticized you and, I believe, the foundation for becoming, in their view, too cozy with the Clinton administration’s health care reform effort. When you think back, what are your thoughts about that whole episode? Schroeder: It was an example of execution trumping strategy. To establish the background of that issue, we were asked by the Clintons to have a series of four exploratory meetings early in 1993 to educate them about the problems they might face in undertaking health care reform. The Clinton task force had just been set up, and we sponsored field hearings in Florida, Iowa, Michigan, and Washington, D.C. in early 1993. I served as the moderator. The meetings themselves, I thought, went very well. I have shown the transcripts to people who were very critical of us, and they didn’t have much of a comeback. But the symbolism was very powerful and made us appear to be partisan. I think we should have given more of a voice to members of the opposition, not just made it an administration road show. I’ll take the responsibility for that. It happened on my watch. Iglehart: After this saga occurred, did it prompt the foundation to change its policies or processes? Schroeder: Our board could have said, "We don’t like to be criticized, especially by one of the two major political parties." They could have said, "Schroeder, you’ve had a chance. It didn’t work out. You go." But they didn’t. They said, "Let’s learn from this, let’s be smarter." In staying with our campaign to expand health insurance, this is what we have tried to do. But we are clearly much more sensitive about politics and how to avoid getting caught in the middle of highly partisan issues.
Iglehart: You’ve been close to the health policy process for many years, having served on the Prospective Payment Assessment Commission, having testified before Congress, and having spoken at and participated in countless Washington conferences. What’s your view of the policy process? Do you despair? Is it a reflection of our society, of the electorate? Schroeder: It is like making sausage, but given all of the ingredients, I don’t think that it’s that bad. What does bother me is the large proportion of our population that seems to have turned its back on government, particularly younger people. Many don’t bother to vote. They don’t perceive that they have access to the political process. So, if you have a democracy that isn’t perceived to represent over 50 percent of the public, then you have to worry. I do have great respect for the people in Congress and in regulatory agencies who work on health policy issues. They are very competent and highly trained, work very hard, and have integrity. The risk, I think, is that in too many instances they view the average constituent of their policy prescriptions as another congressional staffer or bureaucrat. I worry that some of the people, particularly the younger staffers on the Hill, are estranged from what is happening beyond the Beltway, from concerns like illness and poverty. Iglehart: Having gone through our own family experience with serious illness, I have thought that what a lot of healthy people who craft policy need is a good illness to really increase their sensitivity to the ways of the medical and insurance worlds. Schroeder: I couldn’t agree more. Of course, nobody wishes illness on another person, but it does change your mind and your outlook. Iglehart: What about your own family experiences with serious illness—the unfortunate bouts with cancer that you and your wife endured? How did that change your lives? Schroeder: Both Sally and I are very upbeat, glass-half-full people. My illness didn’t change my life, except I couldn’t believe that I had bladder cancer. I wasn’t a smoker, which is the main risk factor. There’s sort of an irony to that. My physician believes that he got all of the tumor. And I frankly don’t think about it very much. So, my life goes on. Sally had to go through chemotherapy and radiotherapy in addition to breast surgery. And I was able to care for her in ways that she hadn’t needed previously. So, in a way, it brought us closer together. Life looks a little more precious, a little sweeter after those illnesses. Both of us are back, fully functional. We don’t have any limitations from our surgery. We’re optimistic. But the cancers are gone. If they come back, we’ll have to deal with it. We also felt extraordinarily privileged that we had excellent health insurance, we had excellent medical care, and we had someone in the family who was a physician who could work through these illnesses with us. So, in a funny kind of a way, it made us realize how fortunate we both are. We haven’t had to face the kind of challenge that you did with your son, David. And, obviously, all of us are mortal, and I regard as sort of the ultimate test how one deals with one’s final illness. I hope, for both of us, it’s a long way in the future. But we don’t have much choice about that.
Iglehart: Steve, let me ask you about one of the programs in which the foundation has invested quite a few resources: improving care at the end of life. What persuaded the foundation to launch that activity in the first place, and what has been the upshot of it? Schroeder: It’s a fascinating story. In the late 1980s my predecessor, Leighton Cluff, talked with Bill Knaus, a physician who cared for patients in the intensive care unit at George Washington University. Knaus told of his concern that there were many problems in the system with care at the end of life. Knaus and his colleague, Joanne Lynn, devised a study to address their concerns. It was called SUPPORT—the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. The study, a $28 million project undertaken at five academic medical centers, showed that hospital care of the dying had severe shortcomings. To our great disappointment, the intervention group of patients (those targeted to receive better care) enrolled in SUPPORT did no better than the control group. People were dying in pain hooked up to machines, and they were without a Do Not Resuscitate order until the last moment, suggesting minimal advance planning. Rather than give up, we concluded that the system could be improved, and we developed a three-part grant-making strategy that involves professional education, institutional change, and public engagement. I believe that the RWJ program has improved the care of dying patients. We have a way to go, but I think the country’s making progress, and I’m proud that the foundation has been a part of that, even though it stemmed from a study that didn’t work the way we had hoped. Iglehart: Are there definitive measures that you would cite about impact? Schroeder: Sure, the number of health care professionals who have been trained to do things better, and the explosion of content about care at the end of life in standard medical journals and textbooks. We have not done a repeat population-based survey to determine whether the pain of seriously ill patients is being relieved. There are a number of process-based measures that would indicate that the nation is better prepared now to do a better job with care at the end of life.
Iglehart: Do you anticipate that RWJ’s priorities in relation to end-of-life care, expanding coverage, and its other key areas will remain the same under your successor? Schroeder: I believe they will. We actually had a retreat of our board in June 2001, and we revisited our current priorities in anticipation of the search for the foundation’s next president. Those priorities, as you will recall, are number one, under "health," reducing the harm from substance abuse; number two is to promote healthy people and healthy communities, with special emphasis on greater physical activity. Under "health care," the priorities have been to expand access to basic health care and to reduce the gap between what we know works and what is being practiced for people with chronic illness. At our retreat, the board said that our current priorities are good ones. We’d like to have greater impact, which is the philanthropist’s dream. Now, of course, our incoming president is going to take a look at them, and she may make some changes. Iglehart: Risa Lavizzo-Mourey, a geriatrician, who was named as your successor this past summer, joined RWJ’s staff as a senior vice-president and director of its health care group only eighteen months earlier. Steve, when you arrived at the foundation in 1990, the board was, almost to a person, white, male, and older, and mostly corporate. Twelve years later the board selects an African American woman as RWJ’s chief executive officer. That’s quite a statement. Schroeder: Over time, our board has become more diverse. It’s younger. It better reflects the gender and ethnic composition of our country. Regarding our staff, the board’s search committee selected Risa because it felt that she was the best person for the job. In my view, she’s an outstanding choice with a diverse set of experiences in government (the Agency for Health Care Policy and Research), academe (University of Pennsylvania), and health services research (geriatrics). She’s terrific with people. She’s a great spokesperson. And her values are really outstanding. It was that combination that impressed our board and led to her selection. Iglehart: What are your future plans? Schroeder: The board has been generous enough to facilitate my relocation back to San Francisco, where I will be rejoining the faculty of the University of California. I will be running a Center on Smoking Cessation and Health Professionals and will undoubtedly become involved in other activities. I have an example of a very energetic father, who turned ninety-five this past October. If I do half as well as he does, I’ll be kicking up my heels for quite some time.
Steve Schroeder has been president of the Robert Wood Johnson Foundation since 1990 and its chief executive officer since 1999. He retires from that position in December 2002. John Iglehart is founding editor of Health Affairs.
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Most Important Achievement
Health Promotion
