With Obamacare Under Fire, What is America's Top Healthcare Funder Thinking?

 A pro-ACA demonstrator in December

A pro-ACA demonstrator in December

Three years ago, when we tallied up philanthropy's greatest hits for 2014, No. 2 on our list was the role of funders in "Making Obamacare Work. " The millions that foundations spent to enroll people in coverage under the Affordable Care Ac ensured that implementation efforts shook off a rocky start and exceeded sign-up goals for 2014. 

Of course, funders also had a hand in getting Obamacare passed in the first place. Atlantic Philanthropies famously gave over $20 million to bankroll an advocacy push for the law in 2009, and over many prior years, a range of funders made the case for universal coverage, with the Robert Johnson Foundation at the forefront of those efforts. 

Today, though, repealing the ACA is near the top of the agenda in a Republican-dominated Washington. Exactly how this might happen, or when—or even if—are all unanswered questions, with the GOP grappling with the grave political risks that repeal could entail, along with the enormous complexity of developing a replacement law. 

These daunting realities, and growing signs that repeal and replacement could take years, may explain why there is no sign of panic about the ACA going away inside the Robert Wood Johnson Foundation—or so it seemed when Inside Philanthropy talked recently to Katherine Hempstead, a senior advisor at RWJF.

No funder has more at stake in the ACA fight than RWJF, which we like to call the "mothership of healthcare philanthropy." Since the law's passage in 2010, it's spent tens of millions of dollars on grants related to the ACA—not just to bankroll enrollment outreach, but also to research and improve the many features of a 2,000-page law that sought to advance a wide range of goals. Improving access to healthcare for the poor, underserved, young, and the uninsurable with pre-existing conditions are the best known of those goals. But the ACA, as its name suggests, also aimed to reduce the costs of U.S. healthcare—while increasing quality through various mechanisms and experiments. RWJF has been keenly interested in these features of the law, too, making grants related to how the ACA is affecting the behavior of hospitals, doctors and consumers. 

Hempstead said there's a lot of continuity in RWJF's current funding on the ACA right now, but the foundation is also looking at what might happen going forward. "A big focus of our work is to help provide evidence to inform policy discussions about what's going to happen under different scenarios."

With an extended discussion looking likely over how to repeal or replace Obamacare, RWJF's role in supporting data-driven analytical work will make it a critical player in national healthcare policy over the next year or two. 

"We think that there will be continued need for research related to issues like the individual insurance market, the benefits of having coverage, the consequences of losing coverage, and policy options for financing coverage," Hempstead said. 

Among other things, RWJF will be walking deeper into the weeds by awarding a major grant to build an actuarial model with coverage-premium cost estimates under some scenarios being tossed around in Congress.

With many millions of Americans worrying about how a repeal, repair, or replacement of Obamacare will affect their pocket—and expressing those anxieties to their elected representatives—you can see just how important new work on premium costs could be. 

In advocating for greater healthcare equity, one of RWJF's competitive advantages has always been its keen grasp of how new research and data can shape public debates. That wonky worldview is front and center at the foundation at a moment when many funders are gravitating toward advocacy and activism to counter Trump. "We believe we can continue to make contributions through our research that will inform policy discussions,” Hempstead said. 

Whatever happens in Washington in the next two years, the underlying issues around healthcare—access, affordability and quality—won't go away even if the Affordable Care Act does. And nor will the Robert Wood Johnson Foundation, which has over $10 billion in assets.