Amidst 1,000 or so (maybe more?) small foundation grantmakers at this year’s Exponent Philanthropy conference area are a number of particularly intriguing examples of bold philanthropy supported by foundation grantmakers that are not mainstream, not run-of-the-mill, not more of the same. At the Exponent Philanthropy conference, we spotted several examples of small grantmaking to note.

From Chicago, there is the VNA Foundation, dedicated to home- and community-based healthcare for the medically underserved. You might recognize the initials, standing for Visiting Nurse Association. The VNA of Chicago dates back to 1890, but in 1995, according to its website, reconstituted itself as the VNA Foundation, supporting nonprofits carrying out home- and community-based care programs, as the VNA ceased delivering direct services on its own.

Displayed in Exponent Philanthropy’s “Hall of Outsized Impact” was a poster describing VNA’s program of support for free and charitable clinics. On the foundation’s website is a succinct and cogent statement of the rationale for a small funder entering the realm of funding free health clinics:

“To date, healthcare reform has not considered the needs of free and charitable clinics or their ongoing role as the safety net provider, yet we know that there will be people who continue to rely on these clinics for healthcare even after the Affordable Care Act is fully implemented. Illinois Medicaid cuts will further increase the need for free and charitable clinics, as struggling families lose access to services that were once reimbursed.”

Exactly so! For all of the important benefits emanating from the coverage provided through the ACA, there are many people still left uninsured, others burdened by high out-of-pocket healthcare payments, and still more that may want and need access to doctors and nurses who really care about the poor as people and patients. We have no doubt that free clinics are going to be a long-term, crucially needed component for providing the poor with access to health care services.

The “Hall” poster on VNA describes VNA’s special initiative on free clinics, including its grant to “revive and reinvent the long-dormant Illinois Association of Free and Charitable Clinics (IAFCC) in the hope that it would allow the state’s free and charitable clincs to network and collaborate ding a time when national health care reform was impacting all providers and constituencies.” An initial VNA Foundation grant of $13,865 helped launch the process of organizing the association and the foundation has since provided $75,000 a year for three years running for its support.

As a result of the VNA’s important front end funding, the IAFCC is alive and apparently very active. On the IAFCC website, there are several useful resources to practitioners and to people in need informing them about the array of free clinic resources in the region. In addition, there is an important report on a statewide survey of health clinics, describing what the array of 21 free clinics are actually delivering in the state—in 2013, serving 67,861 patients (an unduplicated count), providing 151,824 volunteer hours of service, and adapting as well as possible to healthcare innovations such as Electronic Health Records and data-driven quality improvement strategies.

Why was the VNA support of IAFCC important? Partially it is because the clinics do so much that is simply not covered, by omission or legislative commission, in the ACA—no coverage for undocumented immigrants and no Medicaid coverage for legal immigrants during their first five years of U.S. residency, problems with affordablility of insurance even with federal subsidies, service delivery gaps (for example, generally no coverage of dental care for adults in the ACA), and lack of provider access. By investing in the infrastructure for supporting free health clinics, the VNA Foundation has done much more than deliver services. It has built organizational infrastructure and advanced the capacity of free clinics throughout the state to advocate for better health care services for the poor.

The IAFCC now has more resources than the initial VNA Foundation grant. The association lists support from the Chicago Community Trust, the BlueCross BlueShield of Illinois, and the Community Memorial Foundation. Investing in organizational infrastructure is critically important for moving an issue such as free health care. One might guess that most small funders don’t see themselves as building infrastructure, but the VNA example points out the importance of advocacy and services together.   They aren’t mutually exclusive at all. In fact, VNA’s grantmaking also supports a number of health delivery programs, with grants that seem especially useful and targeted: in 2013, $30,000 to support a mobile dental program at Advocate Illinois Masonic Medical Center, $35,000 for the American Indian Health Service of Chicago for a community nurse to provide diabetes prevention and treatment services, $30,000 to Breakthrough Urban Ministries for a psychiatrist to provide on-site psychiatric services to homeless adults, $50,000 to the Chicago Children’s Advocacy Center for expanded mental health services for children who have been sexually abused, just to name a few. VNA’s total FY2013 grantmaking was $ 2,361,172 in 67 grants.

The VNA Foundation grant for the IAFCC shows that a small grant, virtual chump change for a large foundation, can count for and achieve a great deal, even in a difficult issue area such as healthcare for the poor. Big issues needn’t scare away small foundations. To the contrary, a well targeted grant that promotes advocacy and service, builds capacity, and strengthens an entire field is well within the capacity of small funders. VNA’s free health clinic grantmaking looks like a model worth emulating.