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‘America’s Passing Gear’Private foundations are a very small piece of the action in the United States—their health care spending amounting to less than 0.5 percent of national health spending in 2006—yet Joel Fleishman’s book The Foundation, reviewed by Lewis G. Sandy (Sep/Oct 07), demonstrates that this small group of institutions is often instrumental in improving society. Trenchant analyses like Fleishman’s of foundations are rare but, as Sandy maintains in his review, it can promote better performance by a group of privileged institutions whose achievement record is far from uniformly high. Health care lends itself to the scientific approach to grant making that Fleishman sees as most productive: getting the facts right with research; identifying the problem carefully; assessing options for action; selecting effective change agents; and developing effective action plans with clear goals and benchmarks for assessing results. As a result, foundations focusing on health care have a better performance record than most. Health care foundations have achievements that go well beyond the examples included in the book. The Commonwealth Fund’s success stories, for example, range from developing the Pap smear to rural hospitals’ paving the way for the Hill-Burton Act, the emergence of nurse practitioners and physician assistants, and the hospice and patient-centered care movements. But health care foundations assuredly have many of the shortcomings that both Fleishman and Sandy write about. At a time when the opportunity seems ripe for creating major changes needed to achieve a high-performance health system in this country, every health care foundation ought to take a close look at its goals and strategies and ask whether it is working on fundamental issues or at the margin. As Fleishman notes and Sandy quotes, Paul Ylvisaker said that "philanthropy is America’s passing gear." Our health care foundations should make that their motto.
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