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GRANTWATCH: ESSAYFoundations’ Impact On Health Policy
Foundations have sought to influence health policy in the public, private, and nonprofit sectors for more than a century. Their effectiveness in this has been a result of reliability and relevance in seeking and disseminating information, responsiveness to policymakers’ priorities and operating styles, circumspection in communicating with policymakers and the media, and ability to maintain continuity in the issues of policy that funders address. This paper draws evidence to support these points from the history of foundations and health policy and, in particular, the Milbank Memorial Fund.
FOUNDATIONS HAVE influenced policy for organizing and financing health services when policymakers have trusted them. Trust has been based on shared assumptions about how the politics of policy making is conducted. Foundations whose representatives have chosen to influence policy by advocacy rather than participation in the routine politics of policy making have usually been ignored and even criticized. Most foundation leaders have preferred to present themselves as innovators or as communicators of important ideas. Very few employees and even fewer trustees of foundations active in health affairs have described working in the politics of policy making—for example, serving as surrogate staff to policymakers, helping them negotiate with representatives of interest and advocacy groups, or consulting with them about grants or foundation-sponsored publications that would test the feasibility of potential policy. In 1989 the search committee for a new president of the Milbank Memorial Fund asked me how the fund could influence health policy. I said that a foundation could influence policy if its staff followed four rules. The first of these rules is to maintain access to published and unpublished information that is reliable and relevant to making and implementing policy. I explained that researchers, whether in universities or in think tanks, produce a relatively small amount of such information. Analysts who work for policymakers, directly or through research organizations, produce most of the information that policymakers consider reliable and relevant. First-hand experience in the politics of policy making yields, moreover, information that is rarely, and then thinly, described by journalists, researchers, or analysts. Some of this information is about strategies for mobilizing support for a particular policy among the individuals and organizations affected by it. Much of it is what policymakers have learned about the effects of policies from overseeing their implementation. This experiential information is communicated most credibly among peers in meetings for which there is no public record. The other three rules that enable a foundation to influence policy are procedural. They enable it to establish and maintain relationships with policymakers that facilitate communication and the exchange of reliable and relevant information. The first is responsiveness. When a policymaker tells a member of a foundation’s staff that he or she needs a favor, the answer must always be, "Yes, if it’s legal"; the staffer should never say, "Send us a proposal or a letter," or "I’ll take it to a committee," or "I’ll think about it." Next is circumspection. When a reporter calls, foundation staff should respond warmly, supply reliable information, and then offer telephone numbers of policymakers who would probably be pleased to talk for attribution about the subject. Last is continuity. A foundation must remain sufficiently involved with any issue it has addressed to revisit it rapidly at a decisionmaker’s request. Milbank has followed these rules for the past sixteen years. Each of the fund’s professionals who work with decisionmakers has experience in the politics of policy making. Milbank’s senior editorial staff members are researchers with networks of colleagues who study health services and systems in ways that are relevant to policy. We train administrative staff to assume that every inquiry is or could be from a decisionmaker, a member of his or her staff, or a researcher who has information potentially helpful for policy making. In writing an article on the importance of the fund for policy on the occasion of its centennial, I learned that its leaders had followed similar rules between 1905 and 1961.1 In that article I described Milbank’s current program and also assessed the fund in the context of recent literature about the history of foundations in health. This research led me to hypothesize that although many foundations have offered policymakers reliable information, foundations that have been attentive to rules similar to the four I mentioned have occasionally influenced health policy.
Responsiveness is as important a precondition of trust between policymakers and foundation staff as is access to reliable and relevant information. A responsive foundation welcomes requests from policymakers for information or assistance. Its staff members are knowledgeable and discreet participants in the conversations, meetings, document drafting, and public events that are the daily work of the politics of policymaking. In these politics, trust develops when each person in a meeting or conversation appreciates and respects what the other participants can and cannot support or say in public as a result of their accountability to voters, contributors, and other policymakers. General Education Board (GEB). Here is an early example of responsiveness that was the basis of trust that led to policy that was essential to the reorganization of health services in the twentieth century. In the second decade of the twentieth century, the GEB, a foundation established by John D. Rockefeller, agreed in private conversations with reformers in academic medicine that the health of the public would be improved by a policy of universities and their public and philanthropic funders encouraging medical schools to hire full-time faculty members in clinical disciplines. These physicians would practice, teach, and do research in hospitals that dominated health services in the metropolitan regions or states in which they were located. Many prominent academic physicians opposed the full-time policy because they did not want to exchange fees from practice for salaries. Foundation staff and several medical school deans devised incentives for medical faculty to become full-time university employees. The GEB then awarded grants to implement the new policy.2 These grants influenced policy because the GEB’s staff and trustees were responsive to policymakers. They acceded to requests from several university presidents and medical school deans for flexibility in defining full-time service to accommodate to the local politics of faculty acceptance of the new policy. They also changed the GEB’s policy to permit what was in effect the pooling of state appropriations with money from foundation grants. Committee on the Costs of Medical Care (CCMC). Another instance of foundations’ responsiveness to decisionmakers in the health sector was the establishment and funding of the CCMC in the late 1920s. After consulting leaders of organized medicine, eight foundations (the Carnegie Endowment for the Advancement of Teaching; the Commonwealth, Milbank, and Rosenwald Funds; and the Josiah Macy New York, Russell Sage, and Rockefeller Foundations) financed the committee and charged it to recommend policy to increase access to health services, especially for people with low incomes. The foundations assumed from their conversations with medical leaders that the committee members would agree on policy for changing the organization of and reimbursement for health services. But the representatives of organized medicine who served on the panel wrote a minority report insisting that the policy recommended by the majority would compromise physicians’ autonomy. Leaders of the American Medical Association (AMA) and state medical societies attacked the majority report in their own journals and in press releases.3 Milbank, almost alone among those foundations, continued to support the majority report in public. Moreover, Edgar Sydenstricker, the fund’s research director and a member of the committee, wrote another minority report in which he argued that the recommendations that antagonized organized medicine did not go far enough in advocating collective responsibility for health. Then Milbank hired as a researcher I.S. Falk, who had been a member of the committee’s staff and was a passionate defender of the majority’s recommendations. Because the fund’s assets were heavily invested in securities of the Borden Company, several state medical societies asked their members to urge mothers of newborns to avoid using Borden’s condensed milk in infant formula. The 1930s. One of my predecessors, John A. Kingsbury, then became an advocate. Abandoning the political discipline he had brought to the fund two decades earlier from a career in both government and the charitable sector, he made speeches and wrote articles advocating reform in the organization and financing of health services. Between 1932 and 1934 he pressed President Franklin D. Roosevelt, whom he knew from politics in New York State, to recommend subsidies to help people purchase health insurance in what would become the Social Security Act of 1935. He persisted in his advocacy to President Roosevelt, members of his cabinet, and his White House staff after he knew that the president had decided against including health insurance in his message to Congress recommending Social Security. Milbank’s board, and especially its chairman (who also chaired Borden’s board), became uneasy. In 1935 the board fired Kingsbury and continued to work quietly with policymakers to improve health care and population health.4 Most of the other foundations that had financed the CCMC became cautious about advocating policy to finance and organize health services. Several of them made grants to finance hospital construction, especially in smaller cities, after learning that leaders of medicine, business, and government would support growth in the supply of services as a way to increase access to care. The Rockefeller Foundation strengthened its commitment to improving health by increasing funding for research in the basic biomedical sciences. The 1940s onward. From the 1940s until the 1970s, most of the leading foundations in health accorded priority to science, professional education, and public health services. A partial exception was the establishment of the Population Council by Rockefeller, Carnegie, Milbank, and others. The council became an advocate for family planning as a health service in the United States and developing countries and did research on birth control methods. A historian of family planning explains that it was an issue of policy about which board members of national foundations, most of whose social and professional peers supported birth control, could withstand controversy.5 Most presidents of foundations in health in the first four decades after World War II came from distinguished careers in academic medicine. Although they had mastered the politics of academic health centers and of the National Institutes of Health (NIH), most of them lacked experience in the politics of financing and organizing health services. Beginning in the 1970s, two of the foundations led by academic physicians sought to influence policy for health services. The Robert Wood Johnson Foundation (RWJF) funded demonstrations of innovations in the organization of medical care beginning in the mid-1970s. In the 1990s, notably successful projects risked criticism for what members of its staff recently described as "advocacy and policy change."6 Similarly, the W.T. Grant Foundation sponsored research intended to improve policy for children’s services. During the 1990s many foundations began to accord priority to policy for organizing and financing health services. These foundations included endowments by a single donor or family, notably the RWJF; the Commonwealth Fund; and the Henry J. Kaiser Family, W.K. Kellogg, and David and Lucile Packard Foundations, as well as the California Endowment, California HealthCare Foundation (CHCF), and California Wellness Foundation, each of which was established as the result of the conversion of a nonprofit health plan or insurer to for-profit status. A recent study describes the leaders of these foundations as policy entrepreneurs. It concludes that most of these leaders accorded priority to investments in new information and technical assistance; several regarded themselves as advocates. Nevertheless, only one of the foundation leaders interviewed for the study, Mark D. Smith of the CHCF, considered responsiveness to policymakers to be the first step in influencing their decisions. He told the authors that the "foundation business is the relationship business." Effectiveness, he continued, is a "question of knowing our constituencies, knowing consumers of information well and having enough of a sense of the political, economic and social environment to know when an issue can move and what is likely to move it."7
Foundations that influence policy are usually circumspect as well as responsive and informed. The RWJF’s advocacy for policy to control tobacco was an exception, possibly as a result of strong public antipathy to tobacco and its manufacturers. Because most of the major issues of health policy are more controversial, public advocates make most policymakers nervous. Moreover, policymakers in the public, private, and nonprofit sectors have strong practical reasons for wanting favorable coverage by the media; it attracts or retains votes, contracts, consumers, or patients. In contrast, media coverage of the opinions of foundation executives about controversial issues can reduce funders’ capacity to influence policy. Few foundation executives coordinate ("clear" would be more accurate, if less diplomatic) what they tell the media with colleagues in government, business, or provider groups. Foundation leaders, eager to be noticed by the media, risk policymakers’ perceiving as advocacy what they are quoted as saying. Policymakers are wary of advocates, even advocates for policies that they support, because many of them have been embarrassed by advocacy groups that consider their cause to be more important than trusted political relationships. The rule that foundations should be circumspect with the media is controversial. Drew Altman, president and chief executive officer (CEO) of the highly regarded Kaiser Family Foundation, has argued, for instance, that his organization seeks visibility in the media in order to influence policy.8 However, most media coverage of foundations’ work on policy for health services is rarely evidence of influence. Milbank, for example, received the most extensive coverage in its history between 1933 and 1935 when Kingsbury antagonized leaders of the medical profession by advocating government financing of health coverage for people with low incomes. Foundation staff members who are trusted by policymakers usually know which of them would appreciate being asked for a quote or a sound bite on an issue. They also know which policymakers would appreciate suggestions for quotes or sound bites and whom on their staff to work with in crafting them.
Many policymakers complain about lack of continuity in foundation programs on policy for health services. The priorities and programs of foundations frequently change after the appointment of new CEOs or in response to alterations in their board membership. Policymakers, in contrast, address a stable set of issues, whose salience changes as a result of events beyond their control. Foundations that influence policy are sensitive to quick changes in the priorities of policymakers in different jurisdictions and organizations. Staff members of these foundations follow the politics of policy making on an array of issues that they are not currently addressing in funded projects. Keeping current requires many formal and informal conversations with policymakers and their staffs as well as reading public documents and tracking media reports. Continuity is a fragile asset for foundations. From 1905 to 1961 Milbank’s staff collaborated with policymakers across the United States. Then a new CEO changed the program. He was an expert in community health who was born and trained in Scotland and had worked at an academic health center in Canada before he joined the fund. Lacking any experience with the politics of policy in the United States, he changed Milbank’s program. This redirection continued for three decades. One question that troubles me belongs in a discussion of continuity: How does foundations’ effectiveness in influencing policy to control particular diseases compare with the results of their efforts to influence the organization and financing of health services? From the hookworm campaign of the Rockefeller philanthropies early in the 1900s to the HIV/AIDS, malaria, and tuberculosis projects of the Bill and Melinda Gates Foundation today, foundations have tried to prevent, reduce the incidence of, or even eliminate particular diseases. Policymakers supported many of these programs. For example, business and political leaders in the South, eager to increase the productivity of their workforces, endorsed the hookworm campaign’s focus on changing individual behavior rather than finding the controversial causes of the poverty that facilitated the spread of the disease.9 Similarly, many policymakers in Africa collaborate in the Gates Foundation’s disease-specific programs. But policymakers have also been troubled by disease-specific projects. French officials and health professionals, for example, criticized the Rockefeller Foundation’s tuberculosis program during World War I for being discontinuous with French policy and professional practice.10 Foundation interventions against particular diseases have almost always been criticized by local professionals and policymakers when funding is withdrawn. Policymakers in Southern Africa have complained in my presence that single-disease programs that are sponsored by foundations, multilateral agencies, and donor governments distort their underfunded health sectors and do not contribute to building local capacity. It is difficult to generalize about foundations, however. For example, a historian of the Rockefeller philanthropies’ international programs faults them for a "narrow biomedical approach to public health." But he also writes that the Rockefeller hookworm campaign in Mexico in the mid-1920s "became a wedge for building a permanent health system."11 The author of a recent article on the Rockefeller Foundation’s medical programs in China in the 1930s describes how the foundation moved from disseminating the findings of biomedical research to supporting the improvement of population health through community development programs conducted by Chinese organizations.12 Similarly, the Gates Foundation is funding dissemination of the techniques with which expert committees, appointed by the Institute of Medicine (IOM) and the other National Academies, respond to questions from policymakers. Moreover, Gates recently appointed as its chief operating officer Cheryl Scott, who has had a distinguished career in the management of health services and served as president and CEO of Group Health Cooperative, based in Seattle.
In summary, a foundation’s impact on policy is mainly a result of how its leaders balance their legal responsibilities as fiduciaries for an endowment and its program against their interest in collaborating with policymakers, and how effectively foundation staffs execute the tasks that derive from the decision about balance. Policymakers calculate the extent to which they trust any foundation. Based on this calculation, they give time and attention to a foundation’s staff (or withhold it from them), suggest projects or request assistance or remain silent, and ignore or pay attention to evidence and ideas that a foundation brings to their attention in meetings and publications. There is a price for having policymakers as constituents of a foundation. A foundation that wants to earn and retain policymakers’ trust compromises its effectiveness if it takes public positions on controversial issues, sponsors publications that criticize particular policies, or launches programs that have negligible support among people who run for office and meet payrolls. From conversations with leaders of many foundations that seek to influence health policy, I know that most of them are more comfortable having policymakers as beneficiaries than as partners. These trustees and executives will probably continue to resist sharing with policymakers responsibility for carrying out what the law calls their charitable purpose. This paper suggests that such foundations will contribute mainly—and often in important ways—to discourse about policy, rather than to making and implementing it.
Dan Fox (dmfox{at}milbank.org) has been president of the Milbank Memorial Fund (MMF), an operating foundation in New York City, since 1990. This paper was adapted from Fox’s presentation at the January 2006 "Foundations, Accountability, and Transparency in Democratic Society" conference held at the Pocantico Conference Center, in Sleepy Hollow, New York. The Rockefeller Brothers Fund, Foundation Center, MMF, and Rockefeller Archive Center sponsored the event.
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Responsiveness
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