During the 1993 health care debates, Washington was abuzz with speculation over who had been appointed to the secretive White House task force that was crafting the president’s massive health care reform plan. Unknown to most at the time, five Robert Wood Johnson Foundation health policy fellows working on Capitol Hill had been detailed to the task force—one of them even chairing the committee on quality of care.
In fact, it was the presence of the foundation’s health policy fellows that ultimately tipped off investigators to the fact that non-government employees held high-profile positions on the ill-fated task force. “It was that program that broke the Clinton case,” says Kent Masterson Brown, a lawyer hired by the Association of American Physicians and Surgeons to help ensure that the White House complied with ethics laws. “It was the way we found out that there were private interests on the task force.”
When the White House, in response to a court order, began releasing documents from the task force’s working group, one of Brown’s counsels noticed that several participants were listed as congressional fellows. Brown soon discovered that these positions were paid for by the Robert Wood Johnson Foundation. “So what we had were people who were indeed private citizens, contrary to what [task force head] Ira Magaziner had testified to” in a sworn affidavit.
President Clinton’s health care proposal, of course, went down to defeat. But many of the Robert Wood Johnson Foundation’s health policy fellows have since gone on to distinguished careers within the field, and the program’s stock remains as high as ever on Capitol Hill—especially with the current debate on HMO reform—despite conservative grumbles about what they see as a leftward tilt in the foundation’s grantees.
Managed since its inception in 1973 by the Institute of Medicine of the National Academy of Sciences, the Health Policy Fellowships Program is one of the Robert Wood Johnson Foundation’s oldest and longest-running programs. To date, the program has placed 169 fellows from more than 75 academic health centers in congressional offices. According to program director Marion Ein Lewin, the fellowship’s original purpose was to help academic health centers at the beginning of the growth of health budgets.
But during the late 1960s and early 1970s, the dramatic expansion of public financing in health care had begun to shift health experts’ attention to Washington. Heavily dependent on government grants and financing, academic health centers saw the importance of learning to navigate the complicated and politically-charged budget process. “Very few academic health centers had Washington offices,” says Lewin. “They really had to learn how to make Washington do what they wanted it to do.”
The program was originally restricted to academics from teaching hospitals and universities, giving these physicians a sabbatical to hone their ability to “study health policy and assume appropriate leadership roles in health activities at all levels.” In recent years, however, the increasing entanglement of the federal government and the health care industry prompted the foundation to shift to leadership development and to encouraging long-term involvement in policy-making.
This shift is partly a result of a 1992 outside evaluation that recommended that instead of recruiting exclusively from academic medical centers, the program should “concentrate on developing the career of the most talented health professionals it could find,” regardless of their institutional and professional backgrounds. The program responded in 1993 by changing its eligibility requirements to include people from community-based organizations, managed care organizations, and hospitals. The evaluation also found that the program was succeeding in its objective to create “lifelong involvement in policy issues.”
“As private citizens, fellows were significantly more likely than [non-fellows] to be involved in the affairs of state and federal government and in community and professional activities,” the evaluation stated.
The Robert Wood Johnson Foundation itself has long been a major player in health care policy initiatives, at both the state and national levels. Established in 1916 and made a national organization in 1972, the foundation is the largest U.S. foundation devoted to health issues. Its assets cash in at an impressive $8 billion, and in 2000 the foundation provided nearly $278 million in grants and contracts, focusing on efforts to expand health care coverage, improve care for the chronically ill, and reduce substance abuse.
Over the years, foundation grants have tended to support managed care insurance and government-regulated health care projects, focusing on state-based efforts to convert existing systems into universal coverage plans. In 1990, the foundation helped fund a special commission in Washington state designed to address the state’s health care problems. The result was a highly regulatory state plan, which served as a model for the Clinton plan but was eventually deemed unworkable and was repealed.
Gold Standard Fellows
The fellowship program, recently designated one of the foundation’s “core programs,” enjoys a high profile and is aggressively promoted by the foundation. Since it began, the foundation has spent approximately $15 million to support it, according to Lewin. This figure includes annual stipends—currently $75,000—along with relocation expenses. Fellows most often work for senators who either sit on or chair key health-related committees or subcommittees—namely the Health, Education, Labor, and Pensions Committee and the Finance Committee’s Health Subcommittee—but have also worked with House members and within the executive branch.
During their assignments, fellows assume job responsibilities characteristic of regular Hill staffers, including drafting legislation, briefing members on health-related issues prior to committee and floor votes, conducting background research, organizing hearings, and representing their offices with constituents and at conferences. A program brochure states that fellows “take part in all areas of the policy process, not as onlookers, but as full-time, working participants.”
Placements are determined after fellows interview with congressional offices as a group and then individually. According to Lewin, a fellow’s decision to work in a particular office is often influenced by which party is in the majority and what the member’s specific issues are.
Competition for the fellowships—which Lewin calls “the gold standard of health policy fellowships”—is fierce. To qualify, applicants must be nominated by the chief executive officer of an academic health center or community-based health care agency. According to a program brochure, candidates are assessed based on their “potential for growth and leadership in a health policy setting” as well as on their “potential for contributing to the development of health policy and programs at the national, state, or local level, or. . . at their sponsoring institutions.”
Before beginning their congressional assignments, fellows participate in an intense three-month orientation that includes briefings by executive and legislative branch officials and representatives of health interest groups. Fellows are then briefed on advanced legislative procedures by scholars from the American Political Science Association. These seminars continue throughout a fellow’s assignment.
“The Johnson Foundation is overwhelmingly biased in its approach to health care policy,” argues Bob Moffit, deputy director of domestic policy for the Heritage Foundation, who briefs the health policy fellows each year as part of the program’s orientation period. “It simply doesn’t support conservative health policy initiatives.”
While Moffit says he believes the fellowship program makes a serious effort to expose fellows “to both sides” of the health care debate, he wishes the foundation itself would “move more towards the center and [show a greater] openness to conservative ideas on health care reform.”
Jane Orient is president of the Tucson-based Association for American Physicians and Surgeons, which represents private physicians and was behind the lawsuit that broke the story of the health care task force and the Johnson fellows. She believes the fellowship’s goals are consistent with what she claims is part of the foundation’s overall plan—to place savvy, well-trained policy experts in key positions to promote government-regulated health care schemes.
“They strive to get privately funded people into the government and into state houses,” says Orient, who adds that most cash-strapped government offices are eager for the paid help. “This really shouldn’t be done by private interests.”
Congressional ethics rules currently prohibit registered lobbyists from participating in fellowships where the result of the fellowship would provide “undue advantage to special interests.” The rules, however, do not restrict other participants.
Robert Rubin, a former assistant secretary of Health and Human Services who currently heads the international health care consulting company The Lewin Group and who sits on the fellowship program’s advisory board, says the foundation has “a broad-based approach” to health care. “One needs to look at what the foundation does in its entirety,” says Rubin, not just at “specific issues that some groups choose to criticize.”
Rubin knows something about the program: he served as a 1977-78 fellow in the office of Senator Richard Schweiker, Republican from Pennsylvania, and stayed on as a consultant. When President Reagan tapped Schweiker to head HHS, the latter brought Rubin along.
Past and present Republican senators who have repeatedly requested Johnson fellows include Orrin Hatch of Utah, Bill Frist of Tennessee, and Nancy Kassebaum of Kansas, who sits on the Robert Wood Johnson Foundation’s board of trustees.
“Over the years, I have had the benefit of having some of the finest health care professionals in the country serve as fellows in my office,” says Hatch, adding that the fellows “bring a ‘front line’ perspective to the legislative process.”
In congressional offices, where most staffers are relatively young and have broad liberal arts backgrounds, the opportunity to have a paid, mid-career health care specialist is not often passed up. The program evaluation concludes that congressional offices actively compete for fellows, whose knowledge and experience are highly valued commodites. Since the 1990-91 fellowship year, 41 fellows have worked in Democratic offices while 25 fellows have worked in Republican offices—a tilt Lewin attributes to the larger number of fellowship applicants who favor a more activist government role in health care.
One current fellow, Edward J. Dunn, is a cardiothoracic surgeon from Milwaukee and a clinical assistant professor of surgery at the Medical College of Wisconsin. Dunn says his placement with Senator Edward M. Kennedy, Democrat of Massachusetts, chairman of the Senate Health, Education, Labor, and Pensions Committee, affords him a “nice mix of federal and state policy issues.” Dunn currently has the lead role in negotiating a bipartisan compromise on medical errors legislation and is also trying to establish a new authorization for the Community Access Program, which would provide competitive grants to help upgrade community health centers in underserved areas.
Patience White, a professor of medicine and pediatrics at the George Washington School of Medicine and Health Sciences and chair of pediatric rheumatology at the Children’s National Medical Center, is described by Lewin as this year’s most liberal fellow. But White chose to work with Senator Charles E. Grassley, Republican of Iowa, because she “wanted to branch out.” A leader in the field of moving disabled youth into the workforce, White is helping promote a Grassley-sponsored measure aimed at assisting families with special needs children. She is also working on issues related to welfare reform and medical errors.
“I don’t think you can come into this thinking you are going to change the world,” says White. “My goal is to become more politically astute—to see how policy gets made and how it plays out—and hopefully use that to help people.”
Sheryl H. Blunt is a Washington, D.C.-based freelance writer.