To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology

The appearance of the tenth edition of the Robert Wood Johnson Foundation's To Improve Health and Health Care Anthology is an excellent opportunity to review not only the activities of the nation's fifth-largest philanthropy (with assets of more than $9.3 billion) but also to reflect on health and healthcare philanthropy's development as a discipline and to explore the limits of the field's impact on national healthcare policy. As the nation's single largest health-focused philanthropy, RWJF sees itself as a catalyst for creating and sustaining momentum on critical issues related to health and health care. And well it should; for those seeking a concise, readable, and honest accounting of the practice of healthcare philanthropy at the highest levels, one would be hard pressed to find better.

For the past decade, Stephen Isaacs and James Knickman (who recently left RWJF to become president of the New York State Health Foundation) have shaped this annual publication into a virtual user's manual on healthcare philanthropy; case study after case study (more than a hundred in ten years) have mixed sympathetic, well-written narratives with cold analysis of programmatic successes and failures.

With chapters addressing issues such as quality of care, insurance coverage, and health services for vulnerable populations, the tenth edition of To Improve Health and Health Care demonstrates how, over the course of a quarter century, RWJF has learned to focus its resources to achieve success and, where success proves elusive, to harness the lessons of failure to build better programs and rethink approaches to healthcare reform.

Among the important lessons addressed here is that even while RWJF is a giant among foundations, its financial leverage in a trillion-dollar industry characterized by well-entrenched habits, interests, and bureaucracies is modest, at best. In areas like health insurance, the foundation has pointed the way toward innovations in delivering cost-effective care to underserved populations. And it has lent its voice (through support of marketing programs) to federal- and state-subsidized insurance programs for poor children and their families. But the foundation knows well that it alone does not have the answers, and that broad and lasting progress toward real healthcare reform will not occur without the political will to transform an unwieldy and decentralized healthcare marketplace.

Where RWJF has found that it can be most effective is in areas where policy is not well-formed, innovations are welcome, and success or failure can be measured. The foundation has some well known successes in this regard, including, in the 1970s, supporting projects that led to the development of the emergency-response system known familiarly as 911; and, in the 1990s, leading the way in anti-smoking campaigns on both the health and healthcare fronts. Mentioned in passing (probably because it's still a new focus) is the leadership role RWJF has assumed in drawing attention to the epidemic of obesity in the United States; it will be of interest to watch as that battle is waged over the next decade.

As was true of earlier editions, the tenth edition of To Improve Health and Health Care is distinguished by both the seriousness of the issues it addresses and the thoughtfulness with which its contributors weigh in on those issues. One essay, about the Dartmouth Atlas of Health Care, an RWJF-sponsored project, is worth particular mention. Led by Dartmouth's Jack Wennberg, this nationwide, multi-decade effort has succeeded in mapping the cost and frequency of health care in exacting detail, exposing variability in healthcare services and delivery across the United States. Moreover, by demonstrating how frequency of care does not contribute, statistically speaking, to a patient's longevity, or how the availability of specialists correlates directly to the number of specialty procedures performed, regardless of medical necessity, the Atlas(now online) will likely serve as a rampart from which healthcare reformers will wage battle for years to come.

The Sickness Prevention Achieved through Regional Collaboration (SPARC) program is another example of how, in its preferred role as catalyst, RWJF's leadership has brought innovative ideas to the healthcare field. With relatively small grants of a few hundred thousand dollars, the foundation has managed to bring other organizations, federal and state agencies, and local health systems into a wide network across rural parts of eastern New York and western Massachusetts and Connecticut. By combining efforts and making funds available for promotion and marketing (including a Vote and Vaccinate program), all the while encouraging incremental, measurable efforts, the program dramatically improved the delivery of inoculations and vaccinations in a region with a low-income, largely seasonal labor force often lacking access to regular health care.

Seldom are forewords to anthologies worth mentioning. But much like the volume itself, the foreword to the tenth edition by RWJF president Risa Lavizzo-Mourey could well (and, by rights, ought to) serve as a template for other foundations looking to organize themselves around a mission. What is so striking in Lavizzo-Mourey's essay (and throughout the volume) is the seriousness with which RWJF evaluates its programs and initiatives and seeks to understand the limits of its efforts. By conscious and transparent example (of which the annual publication of the To Improve Health and Health Care series over the last decade is a testament), RWJF has continually raised the bar in healthcare philanthropy, encouraging others, by example, to adopt similar practices and distinguishing itself as a critical voice in the continuing debate over the need for systemic national healthcare reform.