A conversation with the Robert Wood Johnson Foundation on September 24, 2013

Participants

• John Lumpkin — Senior Vice President and Director, Health Care Group, Robert Wood Johnson Foundation
• Cari Tuna — Co-Founder, Good Ventures
• Sean Conley — Research Analyst, GiveWell

Note: This set of notes gives an overview of the major points made by John Lumpkin.

Summary

Good Ventures and GiveWell spoke with John Lumpkin about his work at the Robert Wood Johnson Foundation, a foundation dedicated to improving health in the U.S. Topics discussed included how the Foundation chooses its projects, strategies it uses to accomplish its goals, the Affordable Care Act, and examples of the Foundation's work.

The Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation works to improve the health and health care of all Americans. The Foundation's programs are divided into the Health Group and Health Care Group, which Mr. Lumpkin oversees. The Health Care Group includes four program areas:

1. Increasing the number of Americans with stable and affordable health care insurance. The annual budget for this program is about $30 million.
2. Improving the quality and equity of health care delivery. The annual budget for this program is about $45 million.
3. The human capital program, which invests in individuals (mainly through scholars and fellows programs) to create a foundation for social change. The annual budget for this program is about $70 million.
4. Pioneer, which looks for unconventional solutions to health problems in the U.S. The annual budget for this program is about $25 million.

The Foundation has a strong commitment to generating knowledge through its work and communicating that knowledge to a wide audience.  

The Foundation's annual grant making for the last 4 or 5 years has been roughly $400 million.

Choosing projects and identifying grantees

In the past, the Foundation's grantmaking was structured around program areas. More recently, the Foundation has shifted to a more strategic approach, which involves:

• Formulating one or more long-term goals. A major goal of the Foundation currently is to ensure that 95% of Americans have affordable health care by 2020.
• Creating a logic model for how to accomplish the goal. For example, the Foundation believes that working to improve the implementation of the Affordable Care Act will increase the number of Americans with affordable health care.
• Determining the steps to take and the metrics to measure intermediary performance. For example, the Foundation is currently working on ways to make sure states implement the Affordable Care Act in a way that is conducive to people signing up with minimal administrative burden, and educating the public on what options the legislation gives them.
• Making grants consistent with these steps.

The new approach seems to have yielded better results. The Foundation has used this approach to combat childhood obesity. The area received little attention before the Robert Wood Johnson Foundation entered the field. Now there is evidence that the childhood obesity is not only slowing but starting to reverse.

National program offices

The Foundation uses national program offices to distribute most of its grants. The offices help bring in expertise while keeping administrative costs down. For example, the Foundation placed a national program office at Princeton University and hired a former state health director who came in as a national program director. She works to identify individuals who can give technical assistance to states that are trying to implement health insurance exchanges and Medicare expansion and that are in the process of creating rules for enrollment and subsidies. Those individuals have provided technical assistance to states that couldn't get it elsewhere, including some states that had funding for this purpose but were unable to access assistance due to their procurement processes.

Affordable Care Act

The Foundation has been involved in the issue of expanding access to health insurance since its founding 41 years ago. About a decade ago the Foundation launched a major initiative to help children get enrolled in Medicaid and state insurance programs. Through that work, the Foundation learned that certain administrative policies can have a large impact on whether people sign up for insurance. The Foundation has funded media campaigns that address the public perception that people who are uninsured are usually unemployed. In fact, 80% of people who are uninsured are employed or children of caregivers who are employed. Health insurance is in fact a working poor issue.

President Obama's election and his strong support for the Affordable Care Act put national attention on health insurance. To capitalize on this political moment, the Foundation made major investments in research and non-partisan policy analysis. It funded the development of a simulation model by the Urban Institute to predict the impact of failing to reform health insurance on premiums, enrollment, number of uninsured people, and other outcomes under various assumptions. The Foundation and the Urban Institute used the model's predictions to publish a series of studies. This research helped to inform the debate on the issue, and members of Congress quoted from some of the Foundation's studies and reports.

Political advocacy

The Robert Wood Johnson Foundation does not get directly involved in the legislative process, and instead focuses on creating research to inform policy debate. As a private foundation, it cannot fund lobbying.

The Foundation has advocated for improved health care, but once there was a bill under consideration the Foundation had to restrict its advocacy. The Foundation has funded the Bipartisan Policy Center, which developed a bipartisan health care plan. The Foundation has also distributed information on the plight of the uninsured, particularly noting the uninsured live sicker and die younger. This type of work is within the law because it does not aim to move towards a specific legislative solution. The Foundation navigates the line between acceptable and unacceptable advocacy with the help of four in-house attorneys.

Notable current projects

• Implementation of the Affordable Care Act: The Foundation has been working with eleven states to assist with implementation of the insurance coverage provisions of the Affordable Care Act.
• Shifting to a regional approach to health care quality improvement: The Foundation spent a number of years working to create good models for health care quality improvement, but found that acceptance of the models was limited. In response to this problem, the Foundation put together a regional approach, which it has been funding for 8 years. The federal government has had two programs based on this design: the Beacon Community Program, sponsored by the Office of the National Coordinator for Health Information Technology, and the Certified Value Exchanges which were designed for the Agency for Healthcare Research and Quality. Improvements in certain regions have already been seen, including improved public reporting of data on quality and improved care for people with diabetes and heart disease.
• Project ECHO: Dr. Sanjeev Arora at the University of New Mexico has used teleconferencing to train other doctors in the state on Hepatitis C case management. Dr. Arora was originally the only hepatologist in New Mexico, a state with 26,000 people with Hepatitis C. The doctors he trained, after a year or two of training, are now able to deliver care nearly as good as the care given at the University of New Mexico. The Foundation has helped to expand and clarify this transformational model, which is now being adopted by the Veteran's Administration (VA). The VA will maintain good data on the success of the project.
• Enroll America: The Foundation has funded Enroll America, an organization that uses sophisticated data and micro-targeting to get individuals enrolled in health insurance plans. This is done by using voter enrollment and other public data to identify individuals who are likely to be uninsured. So far the project has achieved doubled the accuracy in targeting. Another aspect of the project is to use polling, focus groups and modeling to predict the effectiveness of various outreach methods, such as mailings and in-person visits.

A key opportunity for additional funding in this field is further study of the impact of broader characteristics on health, such as education, poverty, and the environment an individual lives in. This work might involve building partnerships with other philanthropies to study those issues.