In 1997, a few visionary leaders created what was then Guilford County’s only health-related philanthropic organization. These leaders pictured a prudently-managed grantmaker overseen by a diverse board of community leaders, and staffed by a team of professionals with deep knowledge of the community’s health needs and resources that would be dedicated to creating a healthier community. To date, Cone Health Foundation has made grant investments of $86 million, spread over 1,500 grants in four priority areas (access to care, adolescent pregnancy prevention, HIV, and mental health and substance use disorders). We have learned a few things along the way: maintain a laser-like focus, invest in sound science, and build strong partnerships.
A coalescing of these lessons-learned occurred on March 23, 2010, when President Obama signed the Affordable Care Act (ACA) into law. Like much of the health reform preceding it, the ACA is confusing, frustrating, and incomprehensible to most. Cone Health Foundation understood that, while recognizing the promise the law held: greater health care coverage, especially for our most vulnerable neighbors – a promise that perfectly aligns with our priority areas.
How does a local funder use all the powers of philanthropy–our assets, our voice, our convening power–on national health care policy as complex as the ACA? We were working without a net in those early days of the ACA. There was no playbook about how to wade-in on such a politically-charged issue. Having a board willing to take risks and understand we were on the precipice of great change in the health care landscape meant we needed to lean-in to all the possibility the ACA held.
However, we also understood that the success of the ACA reforms was not guaranteed and would depend largely on strong outreach and education efforts. Lack of awareness, poor health literacy, and limited resources to support these efforts were all national in scope, but local in nature. The opportunity to support these kinds of efforts came through NC Get Covered, a statewide collaborative of nonprofit organizations, medical providers, and social service agencies, whose mission was to help uninsured North Carolinians understand and enroll in new health care coverage options provided through the ACA. The foundation’s support of this collaborative work has been steady for the past five open enrollment periods.
Our participation with the NC Get Covered coalition gave our staff and board deeper insight into all of the complexity and challenges with health care reform–from technical difficulties with healthcare.gov, to economic factors affecting individual insurance market plan premiums, to the state legislature’s decision not to expand Medicaid–and a greater appreciation for the far-reaching impact that policy decisions can have, particularly for people who are already marginalized.
From a public health perspective, the implications of the decision not to close the health insurance coverage gap through a Medicaid expansion, are enormous. Research tells us that the uninsured experience sicker lives and poorer health than others and that participation in Medicaid helps the previously uninsured avoid the strain of catastrophic medical expenses.
These troubling public health trends prompted Cone Health Foundation, in concert with the Kate B. Reynolds Charitable Trust, to commission a nonpartisan, first-of-its-kind, study by prominent researchers at George Washington University that assessed the impact of not expanding Medicaid in all 100 North Carolina counties. The study clearly demonstrates that the cost to the state of expanding Medicaid is low, compared to the economic boom it brings.
On reflection, the study was a resounding success based on new relationships forged, media hits, and infusing the Medicaid expansion conversation with solid research. Cone Health Foundation became the de facto, nonpartisan face of Medicaid expansion in North Carolina for over a year. At the same time, the process of working with the researchers, vetting the study, and the endless details that go with media attention taxed a staff of five. Our Board and staff would do it all again. Medicaid quickly becomes a partisan issue in North Carolina, but the Foundation’s work is about people–not politics. Helping our policy makers understand the economics of their decisions is right where we needed to be.
North Carolina remains one of the 17 states to not accept federal funding to close its health insurance coverage gap. However, Cone Health Foundation has watched (and supported) new statewide coalitions advocating for greater health care access. We support those coalitions because we know supporting public policy advocacy is an excellent way to leverage our limited grant dollars to create sustainable change.
Our ACA journey has illuminated the importance of public policy advocacy. For instance, we know state legislators enter office with a wide variety of backgrounds and quickly assume responsibility for serving on committees and casting votes on all matters of state legislation. Decisionmaking on health-related policy is one of the most important roles of legislators in the North Carolina General Assembly, given the size of budget outlays and the impact on individual health, community health and the state economy. That is why we support a nonpartisan, multitiered approach to provide educational resources and inform health-related policy decisionmaking led by our North Carolina Institute of Medicine. We also support the North Carolina AIDS Action Network (NCAAN), another statewide coalition dedicated to improving the lives of people living with HIV/AIDS and affected communities through outreach and public education, policy advocacy, and community-building. These are a few of the reasons why we are focused on advocacy and public policy. It affects everything we, and our grantee partners, do to deliver compassionate, holistic care to vulnerable populations.