Case Study: Shifting the US Health System

October 15, 2018

In our 2017 report Scaling Solutions toward Shifting Systems, we profiled Health Leads, which “strives to inculcate a deeper understanding of the unmet social needs of patients into the healthcare system to shift that ecosystem towards creating health,” in founder Rebecca Onie’s words.  She emphasizes the importance of funders providing long-term, flexible funding for causes and organizations that will create sustained changes to systems to improve people’s lives.

Since handing over the reins to a new CEO, Onie has partnered with Rocco Perla, formerly Health Leads’ President and a leader at the Centers for Medicare and Medicaid Services Innovation Center, to explore the radical notion that while our country is divided on healthcare, we are – or could be – united on health.  Healthcare is a fraught issue in the US, mired in competing economic and political realities. Through public opinion research, Onie and Perla have found that, while people and institutions hold divergent views on healthcare, they hold substantially aligned views on the drivers of health – such as healthy food, safe housing, and well-paying jobs. This alignment transcends race, age, gender, geography, and politics,

This work has culminated in a nascent change strategy. According to Perla, “If we invest only in disparate organizations and institutions, but don’t pull a complete set of levers to achieve impact – spanning policy, practice, and politics – we’re unlikely to see the shift in investment in healthcare to investment in health.”

The organization’s initial funding comes from a small cohort of donors, including several anonymous individuals who have been on this journey for over a decade and are willing to fund the exploration of this new effort. As Onie explains: “Many of these donors thought a combination of good ideas, scaled execution, smart policy, and quality data would be sufficient to realize our vision and stimulate transformation, but now recognize that this just was not enough.”

Onie and Perla have studied deeply successful movements in the US, such as marriage equality, and the behaviors of donors in enabling such fundamental change. Fortunately, the donors invested in the exploration of this next phase of evolution from healthcare to health share some of those critical characteristics. According to Perla: “Our first-stage investors understand that funding the next organization or policy initiative is necessary but not sufficient, and have joined us in asking how we can start charting a course to achieve sustained impact, recognizing that the timeline may be 20+ years.”

For example, the Physicians Foundation—which has also funded Health Leads and whose Board includes 19 state medical societies in red, blue, and purple states — has contracted with Onie and Perla and their team as strategic partners to elevate physician voices across the country on the impact of poverty on health outcomes and cost, as well as the physician and patient experience.

But not all funders are willing to do what it takes. “While a growing number of funders may say they’re committed to systems change,” explains Onie, “and their consultants and advisors promise the same, in reality their work is functionally about scaling organizations. The funder collaboration on marriage equality was spurred by losing ground for 20 years and, in the face of this, recognizing that they had to be willing to fund high-risk, long-term work.“ Onie adds, “To the extent that funders today are talking about systems change, they expect total, rapid transformation with very little money and zero risk to their investment. This is simply impossible.”

Drawing on philanthropy’s pivotal role in marriage equality, Onie and Perla believe in a unified investor framework that tracks wins and losses and frames strategic investments choices for the next year. Explains Perla: “None of our individual donors have asked for a report in the first nine months. Instead, they want us doing the learning required to create sustained impact.”

Nevertheless, the next phase will be a test, since they have “memorialized” some of their hypotheses into a strategy that now needs to be supported. Will more traditional funders be willing to take the requisite risks in shifting the US system to promote health? “What we are trying to do is incredibly ambitious, and it’s probably impossible, but fifteen years ago everyone thought marriage equality was too.”

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