Editor’s Note: This article quotes unnamed sources, which is contrary to NPQ’s standard editorial practice, however the Cohen Report was granted access to this conference only on the condition that any quotations used would not be attributed to specific speakers.


As the saying goes, it’s all over but the shouting. That fits national health care reform, right? Not at all. Philanthropy New York, New York University’s Robert F. Wagner Graduate School of Public Service, and Duke University’s Center for Strategic Philanthropy and Civil Society recently held a “Money and Power in Post-Election America” conference in New York City (tellingly subtitled “Where Is Philanthropy?”). One conference panel explored foundations’ political advocacy roles in the implementation of the Affordable Care Act. That exploration underscored challenges that should motivate nonprofits of every type. It should also spark questions about how institutional philanthropy envisions itself empowering the nonprofit sector to take a role in shaping the implementation of the new and as of yet untested healthcare reform law.

In the lead-up to the health reform legislation, the mobilization of nonprofit advocates was essential to pushing the Patient Protection and Affordable Care Act (ACA) across the finish line, as one workshop participant put it. The most prominent of the explicitly activist efforts to promote national health insurance was the support provided by Atlantic Philanthropies for Health Care for America Now (HCAN), a 501(c)(4) with a 501(c)(3) affiliate, the Health Care for America Education Fund. HCAN was a legislative action campaign with over 1,000 coalition partners that generated thousands of lobbying visits, 873,000 phone calls and over 600,000 faxes to Congress.

For its 2008 launch and its active role in 2009 leading to the 2010 passage of the ACA, HCAN received an investment of more than $25 million from Atlantic Philanthropies. An evaluation of HCAN conducted by Grassroots Solutions and M&R Associates indicated that HCAN had been a “major contributor to passing health care reform,” due in a major way to the Atlantic Philanthropies support that the evaluators characterized as “a calculated gamble that paid off.”

Game over? Declare success and call it a day? Hardly. In some ways, the healthcare reform legislation was simply the starting point of a long, hard slog of implementation that nonprofits have to be prepared to address. It’s time for nonprofits and their foundation backers to redouble their efforts in order to focus on implementation of national health insurance reform. We must not drop the ball now that we come to the tedious but ultimately crucial tasks involved in translating a piece of legislation into a workable program.

Healthcare Implementation Issues and Potential Foundation Responses

Not long after the passage of the ACA, Grantmakers in Health issued one of several reports identifying areas in need of advocacy for the implementation of health reform. The report cited the need for “issue-specific coalitions” to focus on specific aspects of the ACA. It also pointed to a need for developing “overarching blueprints at national and state levels…to identify regulations, timelines, and responsible agencies” in the implementation process. In addition, it considered “defensive advocacy” important in order to fend off attacks such as “state lawsuits and legislation to impede implementation of the PPACA, coupled with challenged state budgets.” There would also be a need, the report said, for “robust outreach and enrollment mechanisms” for the millions of uninsured Americans who would be looking to find new health insurance coverage. After all, the ACA’s passage does not automatically eliminate ongoing challenges in health equity and healthcare delivery.

Then there are the nuts and bolts issues of implementation: operating state-level health exchanges, monitoring the behavior of insurance companies in the states, and getting states to accept expanded Medicaid coverage as a first step toward comprehensive health coverage for lower income people. A publication of the New York State Health Foundation, “Implementing Federal Health Care Reform: A Roadmap for New York State,” adds other issues that have been addressed in the Cohen Report, such as the roles of public and voluntary safety net hospitals under the ACA, the roles of nonprofit hospitals, the functions of community and/or school-based health centers, and the role of state and local health conversion foundations.

But some issues seem to be slipping off of the radar screen, such as capacity building and funding for nonprofit health insurance cooperatives, particularly those that lost funding in the fiscal cliff legislation. What about challenges that may be presented to healthcare consumers by mergers of hospitals and insurance companies, such as the pending merger of Blue Cross Blue Shield of Montana with the Illinois-based Health Care Service Corporation? And who will make sure that we are protecting nonprofit employers’ ability to provide health insurance for their employees? Who will see to it that the ACA’s requirement of community health needs assessments (CHNAs) is used as a blueprint for real healthcare reform as opposed to becoming just one more piece of paperwork?

These issues require on-the-ground advocacy, organizing, and lobbying not just in Washington, D.C., but also in states, regions and even localities across th