When you think about major health philanthropies, the first name that might come to mind — for U.S. work at least — is the Robert Wood Johnson Foundation, a legacy outfit originally founded by a wealthy businessman. Globally, it’s a similar story: The Gates Foundation, for all its uniqueness, remains the project of an uber-rich corporate mogul.
But the same cannot be said for many of the nation’s other largest health foundations, many of which were created through a distinctive legal process. When a nonprofit hospital or health insurer is sold to a for-profit buyer — and many were, in the 1990s and 2000s — regulators often require charitable assets from the sale to be placed in a new nonprofit foundation, as a way to preserve the original entity’s charitable mission. Hundreds of these so-called health conversion foundations now exist across 44 states. These five examples — The California Endowment, Mother Cabrini Health Foundation, the Colorado Health Foundation, Missouri Foundation for Health, and the California Wellness Foundation — are among the largest in the nation, holding roughly $13 billion between them. Each is the largest health funder in its state, or close to it.
These funders back clinics and the local safety net, and also support work around health’s upstream determinants, like housing, organizing, racial equity and policy advocacy. At a time of great uncertainty for healthcare as federal Medicaid and food assistance cuts take a toll, especially among disadvantaged communities, these five funders have acted, including by raising payout rates and getting on board with philanthropic coalitions. Hundreds of other health conversion foundations operate across the country, holding tens of billions of dollars between them.
Here’s a look at what these five notable conversion foundations are supporting and some of the throughlines between them, including, for most, a willingness to lean into racial equity at a time when many other grantmakers have pulled back.
1. The California Endowment
The California Endowment (TCE) held close to $4.4 billion and gave $141 million in 2024. By its own account, it is “the largest private health foundation” in California, and it’s around five times the size of the California Health Care Foundation, which was born from the same 1996 Blue Cross of California deal.
TCE has helped push the bounds of what health philanthropy means, with its approach evolving through the 24-year tenure of former CEO Robert K. Ross. Building Healthy Communities, the foundation’s signature 10-year, $1 billion initiative, treated health as inseparable from organizing, advocacy and civic power. The aim was to engage community leaders to improve health across 14 economically distressed communities. By the time the initiative wrapped in 2020, TCE reported that 83% of BHC grants had been “power-related” — including for community organizing, base-building, policy advocacy — and that its broader power-building support from 2010 through 2019 totaled more than $1.4 billion.
That posture has remained in place into recent years. As president and CEO Brenda Solórzano put it in her May 2025 board statement, the foundation centers “power building as the pathway to justice.”
In May 2025, TCE’s board also raised its endowment spending to up to 10% over three years, potentially adding up to $160 million in grants per year. Solórzano cited “the intentional dismantling of health and social service agencies and the defunding of the Medi-Cal program.” She has separately argued that the 5% private-foundation payout requirement is “the floor,” not a ceiling. Also in 2025, TCE cited 501c4 work as one area of expansion going forward, backing organizations that lobby legislators and run ballot-measure campaigns.
2. Mother Cabrini Health Foundation
Mother Cabrini held around $3.9 billion and gave $172 million in 2024. It calls itself “the largest foundation focused exclusively on healthcare across New York State.” It was created in 2018, when the nonprofit insurer Fidelis Care was sold to for-profit Centene for $3.75 billion. The New York attorney general at the time called the deal “the largest charitable transaction in the history of the Attorney General’s office.”
Mother Cabrini adopted a broad definition of health from the start. Its mission addresses the social determinants of health, defined by the foundation as “economic security, health literacy, availability and access to nutritious food, housing safety and stability, and transportation access and mobility.” Much of this runs through its Basic Needs program area, covering housing, food, economic stability, and benefits navigation, and accounting for $43 million in a recent grant cycle.
The foundation’s work is “motivated by” the example of Mother Frances Xavier Cabrini, an Italian immigrant nun who became the first American canonized a saint and the Catholic Church’s patron of immigrants. Migrants and immigrants have been one focus for the foundation across its program areas. Mental health is another concern: Last fall, Mother Cabrini convened 500 leaders around the issue, from government, health, philanthropy and faith, including the state Office of Mental Health Commissioner and Cardinal Timothy Dolan, the archbishop of New York. Earlier this year, the foundation announced a $142 million grant cycle, framing it as a response to federal funding shifts and targeting childhood nutrition, maternal health and workforce shortages.
3. The Colorado Health Foundation
The Colorado Health Foundation (CHF) was born from a 1995 joint venture between the nonprofit hospital system HealthONE and the for-profit chain HCA; in 2011, it sold its 40% stake for $1.45 billion, a sale that, the foundation says, put the Colorado Health Foundation among the largest philanthropic organizations in the state. It is candid about that lineage: the Denver hospitals it grew out of, it acknowledges, “denied care to Coloradans of color” and did not “meaningfully” integrate until Medicare’s arrival in 1965.
CHF held about $2.8 billion and gave about $102 million in grants in 2024. Since 2011, the foundation has built its strategy around power-shifting and racial equity. The first of its four strategic focus areas is Champion Power Shifting — through which the foundation aims to move money and decision-making toward communities affected by inequity. Affordable Housing is another named priority, framed against “a legacy of discriminatory practices such as redlining and restrictive covenants.”
The foundation reports that 65% of grants since 2021 have gone to programs “where at least half of the people served are people of color,” and that 42% of its 2023 funding went to POC-led organizations. It runs a dedicated Advocacy and Justice With Communities of Color funding line, with two-to-five-year grants to POC-led advocacy groups, and co-publishes an annual ballot-measure tracker with the Colorado Health Institute. In late 2025, CHF criticized the One Big Beautiful Bill Act, projecting that the law’s $1 trillion in Medicaid and SNAP cuts could leave “an additional 150,000 Coloradans uninsured by 2034.”
4. Missouri Foundation for Health
Missouri Foundation for Health (MFH) was created in 2000 from a contested 1998 settlement that forced Blue Cross and Blue Shield of Missouri to convert to for-profit status. MFH is structured as a 501c4, which gives it more legal latitude to engage in policy and advocacy. As of its most recently available 990 filing, MFH holds about $1.37 billion and reported $73.9 million in total expenses in 2023, covering grantmaking plus its policy office and research operation.
Under CEO Dwayne Proctor, who took over in 2021, MFH has focused on antiracism and generational change. The foundation’s stated vision is to be “a trusted antiracist institution.” In January 2023, it launched a 20-year food justice initiative that publicly names food insecurity as the product of “systemic and institutionalized racism leading to racialized poverty.” Proctor explained the timeline at the launch: “True systems change, especially an effort working to reform and reimagine hundreds of years of consolidated and exploitative power, requires a generational commitment.”
In April 2025, the foundation’s VP of health policy and advocacy, Sheldon Weisgrau, warned that congressional Republican budget plans threatened “the very future of Medicaid” as we know it. MFH commissioned Manatt Health to model the impact on Missouri at as much as $3.9 billion a year in lost federal funding and up to 350,000 Missourians losing coverage.
5. The California Wellness Foundation
The California Wellness Foundation (Cal Wellness) was established when the nonprofit HMO Health Net converted to for-profit status. It began its grantmaking in 1992. The foundation says it has awarded more than $1.3 billion in grants and program-related investments over three decades.
Cal Wellness’ interest in addressing the determinants of health goes back a while. In 1993, it committed $30 million to treat gun violence as a public-health problem — at the time, it was the largest private contribution ever to such an approach, which has now gained traction among violence prevention backers nationwide. As of 2024, the foundation held about $1 billion and gave about $50 million in grants.
Cal Wellness has responded to the crises of the past few years with additional commitments. Last year, for instance, it put forward $67 million to “support health and racial justice,” citing federal and state budget cuts, draconian immigration enforcement, and nonprofits “being targeted for doing charitable work.” The foundation says it’s on track to give $170 million across 2025—2027 at an 8% average payout rate.
Earlier this year, Cal Wellness cosigned a statement with 24 other California funders, including TCE and the San Francisco Foundation, calling immigration enforcement a public health crisis and urging governors, public health officials and county supervisors to respond by declaring public health emergencies. Shortly thereafter, CEO Richard Tate introduced a new strategic framework that names “race, money and power” as the “most powerful factors shaping health today” and organizes the foundation’s work around three priority areas: healthcare, environment and democracy.
As Tate put it: “The $1 billion we hold today is the people’s money. Returning it, as investments in what makes wellness possible, is the work.”
This article was written with assistance from AI.
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