Foundations Take a Stand — or Don’t — on the GOP Health Plan

Foundations that were instrumental in building the case for the Affordable Care Act seven years ago don’t want Congress to gut the landmark federal health-insurance legislation. But some health-care advocacy groups say the current debate on Capitol Hill lacks an all-out push like the one progressive foundations made when the law was being created.

“The foundation community that played such a vital role in enabling the victory has significantly abandoned the playing field,” said Ron Pollack, executive director of Families USA, a health-care advocacy group. “The majority of foundations, by and large, moved on. It was as if a banner was raised that said, ‘Mission Accomplished.’ ”

Mr. Pollack cited the Public Welfare Foundation as a big player before passage of the Affordable Care Act, also known as Obamacare, that has turned its attention elsewhere. And Atlantic Philanthropies, a leader in health advocacy during the Obamacare debate, is spending down its endowment on a variety of domestic and international priorities. It announced its last grants late last year.

After spending $18.3 million over three years, the Public Welfare Foundation ended its health-policy program in 2010 after President Obama signed the Affordable Care Act.

However some foundations, such as the California Endowment, are digging deeper. In December, it announced a three-year, $25 million commitment called Fight4All that will make grants to groups that push to retain health coverage for low-income and undocumented residents of the state.

Other major health-care grant makers such as the Robert Wood Johnson Foundation and the Commonwealth Fund have remained focused on the issue but are leery of stepping too far into the debate on particular pieces of legislation.

Both organizations support increasing the number of Americans who can afford high-quality treatment in doctor’s offices, clinics, and hospitals. But rather than duking it out in a public debate over specific bills, their preferred approach is to support independent, authoritative research about the impact of various policy alternatives. For instance, how much would premiums change under a replacement bill? Would they change for disabled people or the elderly?

Answering questions like these has become more of a challenge during a Trump presidency, say some foundation experts, with the president and others questioning once irreproachable information sources, including nonpartisan government offices and reports.

But with Congress digging into the GOP proposal, foundations will provide an essential service, said David Blumenthal, president of the Commonwealth Fund. He wants to position his fund as a trusted source of analysis.

“Despite the indictment of evidence and the tendency of some groups to ignore it, or put out untrue information as fact, there are members of Congress who have been surprised as they have learned about health care” and the impact of policy changes, he said. “We still believe that information can make a difference.”

The Commonwealth Fund has not made any major shifts in funding to prepare for the debate. But Dr. Blumenthal said he has pushed grantees to provide reports that deal directly with the language in bills being debated on Capitol Hill.

“We’ve moved up deadlines and accelerated the pace,” he said. “We’ve asked grantees to re-orient their work.”

Unbiased Information

Last week, the Congressional Budget Office predicted that the current Republican proposal would leave 24 million more Americans uninsured by 2026.

Risa Lavizzo-Mourey, president of the Robert Wood Johnson Foundation, described a ripple effect if it becomes the new law. Not only will individuals’ health suffer if they delay preventative care because of a lack of coverage, she said, but entire communities could suffer economically, prompting a need for more nonprofit services.

“Health-care expenditures have a big impact on people’s overall financial security and well-being,” said Dr. Lavizzo-Mourey, who plans to leave her post next month. “Without health-care insurance, that’s only going to get worse.”

As debate unfolds on Capitol Hill, Dr. Lavizzo-Mourey said it “becomes very difficult” for foundations to advocate for specific policies. Rather than push for any particular bill, she said, Robert Wood Johnson will attempt to provide unbiased information.

“It’s critical that foundations play a role in helping inform the public and policy makers,” Dr. Lavizzo-Mourey said. It’s a part Robert Wood Johnson and other progressive foundations played in the years preceding the enactment of the Affordable Care Act, when they spent millions of dollars on research used to undergird various aspects of the final legislation.

Other foundations worked in the trenches. Atlantic Philanthropies provided $26.5 million in direct support to grass-roots efforts that pushed directly for Obamacare. It was part of a larger effort funded by other organizations including the California Endowment, billionaire donor George Soros, and the Service Employees International Union that gave to 501(c)(4) advocacy groups such as Health Care for America Now.

Atlantic was able to do so because it wasn’t bridled by IRS rules on political activity like other foundations, because it’s registered in Bermuda.

Private foundations incorporated in the United States are limited in how much of their budget they can devote to lobbying and in most cases must be careful not to endorse or criticize specific pieces of legislation.

Gara LaMarche, who headed Atlantic during the Obamacare debate, said he understands why foundations want to be careful about wading into politics. But he said independent research provided by Robert Wood Johnson, Commonwealth, and others was valuable to his group’s direct campaign.

“That’s a very important role,” he said. “We were building on the work other funders had done for years on policy.”

Mr. LaMarche said he is pressing individual philanthropists to support health-care advocacy through the Democracy Alliance, a network of progressive donors that he leads. He is not aware of a large push by foundations to support advocacy during the current health-care deliberations.

Atlantic Philanthropies plans to spend down its endowment by 2020. One of its last big bets on health care was the 2015 creation of the Center for Consumer and Community Engagement through a $14.8 million grant to Community Catalyst. The center aims to give health-insurance consumers a voice in policy debates.

Foundations that support broader access to health care but that don’t increase their advocacy game aren’t working at their potential, according to Sean Dobson, who led grass-roots efforts in Maryland supported in part by Atlantic. While direct lobbying is prohibited, Mr. Dobson, a philanthropy consultant, said foundations can provide general operating grants to groups that do engage politically and can help build popular support on issues without lobbying.

“It’s time for a gut check,” he said. “In Trump’s America, foundations can’t be squeamish about advocacy. If foundations stay on the sidelines, it would be an incredible dereliction of duty.”

Job Losses

Many foundations don’t directly take positions on health-care policy, but they provide general support for organizations that are active in the policy arena. For instance, the W.K. Kellogg Foundation, a longtime health-care player, has made grants to groups like the National Health Law Program that mobilize supporters.

The prospect of big health-policy changes didn’t prompt a radical shift in course, according to Alice Warner, the foundation’s program director.

“We didn’t want to be reactive,” she said, explaining that the foundation is more focused on executing a long-term health-care strategy at the local level in the communities it serves.

Others, like Steven Marcus, president of the Health Foundation of South Florida, see the potential for change in policy as a call to get more involved. He fears that federal caps on Medicaid funding as laid out in the GOP bill circulating in the House will result in a decline in health care among his region’s poorest residents. Also, he predicts, reduced Medicaid coverage will cause “substantial” job loss at health centers that serve low-income residents.

One of the foundation’s grantees, Catalyst Miami, has taken this message to Tallahassee, the state capital, where it is attempting to show the media and policy makers the impact the proposed health-care law would have on providers.

Those efforts, Mr. Marcus says, will be more effective at ensuring sufficient health care than if the foundation had delved into supporting direct services to patients. If Obamacare is repealed, he predicts, state budgets will experience a gap too big for philanthropy to fill.

“We’re not going to solve these things by giving a clinic $10,000 for 1,000 vaccines,” he said. “This isn’t a mega-infusion of services. One of our major roles is getting people who provide the services to tell their story. Success lies in systems change and policy change.”

If tens of millions of people were kicked off of their insurance, as the Congressional Budget Office predicts would happen, state budgets would be under enormous pressure, said Drew Altman, president of the Henry J. Kaiser Family Foundation, a private nonprofit that provides news and research on health care. Foundations that make grants to health-care providers would face a huge dilemma, he said. It would be impossible for them to fill all of the health-care needs that would arise.

Foundation leaders, such as Robert Wood Johnson’s Dr. Lavizzo-Mourey, believe the grants they directed toward informing lawmakers and the public during the Obamacare debate was well spent. The law remains controversial and has stayed in the cross hairs of Republican legislators since the day it took effect. But Dr. Lavizzo-Mourey said the millions of people with coverage for the first time “have a very different view” of Obamacare.

Dr. Altman agreed that foundation-supported research helped legislators as they worked on the Affordable Care Act. But he is wary of overstating its importance.

“It’s a mistake to think that foundations as a whole can affect a $3 trillion health-care system that’s dominated by commercial interests,” he said. “Foundations can try and keep the focus on people, not politics or commercial interests, but at the end of the day, foundations are modest players.”