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Policy Matters: How the Affordable Care Act Has Changed Our Grantmaking

January 2017

Jennifer Oldham, Program and Communications Officer, The Healing Trust
Beth Uselton, Program Director of Advocacy and Access, The Healing Trust

Health reform is not for the faint of heart.

When we began drafting this article, it took shape as a reflective piece on the ways in which the Patient Protection and Affordable Care Act (ACA) had affected our grantmaking. Now, with an election behind us and new federal health policy changes on the horizon, this task gave us reason to pause and consider what we have learned in such a dynamic time that can prepare us now to effectively pursue our mission in a new era of health care reform.

This time of uncertainty is a prime opportunity to practice adaptive leadership and to reaffirm and rely on the strong partnerships we have built with grantees. Adaptive leadership calls on us to be flexible and strategic as we navigate changing times. We will have to accept that our grantees do not have all the answers right now; that we do not have all the answers right now. We are called to keep the conversations open, remain committed to our grantee partners, and to trust the capacity they have built to respond to opportunities and challenges on behalf of those they serve and represent.

Our History with Health Reform

As a private, health-focused foundation, our early years of grantmaking primarily focused on programs that demonstrated concrete, measurable health outcomes for vulnerable patients. It evolved over time to include supporting health advocacy organizations that focused on systemic changes to the healthcare system to better meet the needs of underserved populations.

An opportunity to support advocacy presented itself through an invitation to participate in the Get Covered Tennessee Initiative. Get Covered Tennessee is a statewide collaborative of nonprofit organizations, medical providers, and social service agencies whose mission is to help uninsured Tennesseans understand and enroll in new health care coverage options provided by the ACA.

The collaborative was formed in partnership with the State of Tennessee’s Health Insurance Exchange Planning Initiative in 2012. At that time, the state was weighing its options to create a state-administered exchange and it contracted with us to conduct strategic planning, engage potential partner agencies, and develop a grants program for outreach and enrollment efforts.

Governor Haslam opted not to pursue a state-based marketplace, but the project continued as a private collaborative, and we stepped up our commitment to provide backbone support for the statewide effort – coordinating communications, providing policy analysis, and facilitating trainings and technical assistance for all the partners in the project. We recruited a diverse Advisory Council of community leaders, insurance industry representatives, advocates, medical providers, researchers, and foundation executives. Through the first three open enrollment periods, this group advised and provided technical assistance to the Get Covered Tennessee network of organizations, which included federally-funded Navigators, Certified Application Counselors, federally-qualified health centers, nonprofit organizations, hospitals, charitable clinics, and an extensive network of volunteer assisters. We continued to provide coordination support for the Advisory Council, which sunset in September 2015.

We also developed a one-time cycle of grant funding in 2014 to cover the first two open enrollment periods for the new health insurance marketplace. These one-year grants were awarded to 12 nonprofit agencies that committed to working in partnership with one another to provide community outreach, public education, and specialized enrollment assistance throughout our funding region of middle Tennessee. Together with other statewide partners in the Get Covered Tennessee network, their efforts helped hundreds of thousands of previously uninsured Tennesseans enroll in affordable health insurance coverage and access health care. Although this specific grant program has ended, we continue to support enrollment assistance through program grants.

Our participation in the Get Covered Tennessee project gave our staff and board insight into all the complexity and challenges with health care reform – from technical difficulties with healthcare.gov, to the state legislature’s decision not to expand Medicaid, to economic factors affecting individual insurance market plan premiums – and an appreciation for the far-reaching impact that policy decisions can have, particularly for people who are already marginalized. We also saw, time and again, how a broad-based coalition can effectively respond to these challenges together and successfully advocate for system-wide improvements.

Where We Are Now

Our board and staff were compelled by their experiences with Get Covered Tennessee and how the coalition had addressed the barriers of our grantee partners to best serve their clients. The initiative prompted the board to consider how it could include advocacy as part of its grants programs. Upon learning from grantees that no other local foundation supported this type of work, a board member passionately framed the issue: "If not us, then who?"

In 2015, The Trust rolled out a new Advocacy grants program to provide support for nonprofit partners advocating for policy changes and program improvements that advance health outcomes for vulnerable or underserved populations in Tennessee by either increasing access to health services or preventing childhood trauma. We created two types of advocacy grants to support organizations in different stages of advocacy:

  • Multi-year, unrestricted advocacy grants
  • One-year advocacy capacity-building grants

To date, we have made grants to 17 nonprofit organizations working on issues as diverse as supporting mental health parity, expanding substance abuse treatment for pregnant women, employing telehealth for rural access, preventing child abuse, and expanding Medicaid.

Our approach with these grants has been to focus on the grantee partner’s capacity for advocacy, rather than on the achievement of explicit policy goals. This means that they can leverage the exact same communications infrastructure, coalitions, relationships with policymakers, research capacity, and employ some of the same strategies that they initially used to try to close the Medicaid coverage gap in order to respond to Medicaid block grant proposals. From the outset, we wanted to support the grantee partners’ abilities to be nimble and respond to a changing environment. The next few years will tell us whether they, and we, have been successful in that regard.

Looking Ahead

The future of the ACA and efforts to replace it will impact nearly every one of our grantees They will have to try to fill in the safety net for those who lose coverage, or through the change in their payer mix or reimbursement rates for services, or due to the changes in Medicaid that will result from a Medicaid block grant, or due to effects on federal funding of the programs they deliver. 

If consumer protections in the ACA are to be preserved, our grantees, and other consumer advocates will be the ones who have to fight for them. If premium tax credits are on the chopping block, navigators will have to speak up for low income families who will lose their coverage without them. If Medicaid dollars come to Tennessee in the form of block grants, those who work with Medicaid beneficiaries will need to give them voice in the negotiation around new benefit structures and eligibility rules. If the state chooses to pursue any of the mental health treatment reforms they were exploring under Medicaid expansion, our mental health partners will need to help policymakers understand how to implement them. If hundreds of thousands of Tennesseans lose the health insurance coverage they gained under the ACA, the safety net clinics will have to try to meet that need.

This is why we need to pay attention to public policy. It affects nearly everything we, and our grantee partners, try to do to deliver compassionate, holistic care to vulnerable populations. For us, this realization led us to support health care advocacy work alongside direct services. We are hopeful now that our choices to invest in the advocacy capacity of organizations, to support their coalition work, to help convene potential partners, and to commit to learning alongside them will enable us all to address the challenges and seize the opportunities inherent in a new era of health care reform.

After all, if not us, who?