David Blumenthal, MD, MPP, President, The Commonwealth Fund
Laurie Zephyrin, MD, MPH, MBA, Senior Vice President, Advancing Health Equity, The Commonwealth Fund
Not every foundation is comfortable with trying to affect health policy. Policy to achieve health equity is no exception.
Nevertheless, for philanthropies committed to promoting health equity, shaping governmental action at every level is a powerful tool that deserves close examination. No other actor has government’s power—for good and ill—to bring about social change. Put another way, it is hard to imagine achieving an equitable health care system without forceful and consistent government action, as challenging as that may be to bring about.
At the Commonwealth Fund, we have long been focused on shaping national health policy with respect to coverage, cost, quality, and equity. In recent years, we have also embraced the objective of creating an anti-racist health care system. Our Advancing Health Equity initiative has three strategic thrusts, one of which is directly focused on health policy.
The Fund’s first strategy is changing mindsets. Underlying past and present racist structures in our health care system are attitudes, biases, and ways of thinking about race among the many millions of individuals who work daily in our $4.3 trillion health care system. These mindsets are often unconscious and unexamined, but to the extent that they are prevalent—and health care workers are not immune to attitudes that circulate in the larger society of which they are part—they can present significant barriers to lasting and meaningful progress toward equity in health care.
A second strategic thrust addresses the impact of systemic racism on underlying structures in health care by identifying and scaling organizational approaches, methods, and models for combating racism and improving equity in health care. There are numerous approaches, such as improving measures of equity, creating systems to deploy those measures, addressing the equity effects of new technologies, and more. The aim is to create structures and processes that institutionalize efforts to promote equity within health care organizations.
The Fund’s third approach is to identify and promote health policies that advance equity and combat racism while also assessing existing and new policies for their intended and unintended effects on equity in health care.
Though only the last of these three strategies addresses policy explicitly, all are relevant to health care policy. To the extent that the people who work in health care embrace equity and anti-racism, they are more likely to support government action with those purposes. This makes it politically easier for government to move forward.
And once government does act, its policies inevitably work through health care organizations in one way or another. The requirements or incentives created by new health policy—for example, much discussed pay for equity initiatives in public insurance programs—lead health care organizations to seek ways to comply with or promote public purposes. The availability of proven organizational models to increase equity then becomes a critical spur to policy success.
At this point, readers may be thinking: it’s easy to talk about changing health policy but how do you do it without violating the spirit and letter of the laws governing the behavior of charitable entities? We have thought a lot about this, and we start by recognizing two important facts.
First, compared to the health care system, we are tiny. The United States spends the equivalent of our annual budget every 30 seconds of every day, 365 days a year. Second, as a 501(c)(3) organization, we do not and cannot directly lobby or influence legislation, regulation or judicial decisions. We cannot and do not participate in any way in electoral politics. What we do is engage experts and develop and spread accurate, valid and reliable information about our health care system.
So the question is: how does a very small, 501(c)(3) organization make information an effective influence on policy that affects equity in the US? This is a subset of the general question that many philanthropies confront, namely, how do you make knowledge a force for positive change in society.
We make no claims to special wisdom in this regard, but we have developed an approach after considerable reflection. It consists of the 4 Rights—we aim to develop and disseminate the RIGHT INFORMATION for the RIGHT PEOPLE at the RIGHT TIME in the RIGHT WAY.
By the right information, we mean data, perspectives, or analysis that assist policymakers to make better decisions with respect to health equity, or other important objectives. This means, in turn, hearing the views of diverse experts in the field. Additionally, identifying the right information requires understanding the nature of the decisions policymakers can and must address—the fine points of the regulatory, legislative, or judicial questions they are juggling. The right information also brings to the forefront the views and perspectives of marginalized populations who have often lacked voice in the policy process.
By the right people, we mean the individuals whose decisions actually affect the outcomes of interest. To a large extent, this is a matter of targeting the dissemination of information to people that impact the decision making process. These people may change over time, depending on governmental processes. They may also include non-governmental actors whose opinions can significantly influence decisionmakers, including community-based individuals and groups.
The right time is the time when the issue is front and center on the policymakers agenda. These may be policy windows in governmental process, or moments when private actors experience a compelling need to change. No matter how important or pesuasive information is, it may be ignored by busy officials or managers whose agendas are crowded with other pressing matters.
As to the right way, this is the way that is easy to consume and most compelling. Length has become an issue because attention spans are dropping. Also, using social media, video, and other approaches is critical. Pictures and graphics are often more impactful than long reams of numbers.
Using the 4 Rights, we have tried to affect policy in a number of domains that directly impact health equity. These include postpartum coverage under Medicaid as a way of addressing inequalities in maternal health outcomes; the development of metrics for equity that can be used in pay for equity payment policy, including measures for social determinants of health; and expansions of coverage as ways of reducing disparities in access to insurance and care.
In a policy area as complex as promoting health equity, there are no guarantees of success. But we are convinced that philanthropies can make a positive difference through affecting health policy for the better. And we are happy to share our successes and failures with colleagues in the health care philanthropic community.