History of Philanthropy Case Study: The Impact of Philanthropy on the Passage of the Affordable Care Act

Note: Before the launch of the Open Philanthropy Project Blog, this post appeared on the GiveWell Blog. Uses of “we” and “our” in the below post may refer to the Open Philanthropy Project or to GiveWell as an organization. Additional comments may be available at the original post.

Benjamin Soskis, who has been working for us on our history of philanthropy project, has completed a case study of philanthropy’s impact on the 2010 passage of the Affordable Care Act (ACA).

The case study focuses first on the Atlantic Philanthropies’ funding of Health Care for America Now! (HCAN), as well as on HCAN’s activities and impact. The second part of the study surveys the activities of other funders involved in health care reform, such as the Robert Wood Johnson Foundation, the Kaiser Family Foundation, and the Commonwealth Fund.

The case study concludes that, as a whole, philanthropic spending had a critical, though not necessarily easily quantifiable, role in the passage of the ACA. In the following passage, Dr. Soskis quotes HCAN’s Doneg McDonough:

“There’s just no way health reform would have passed without the [philanthropically funded] outside efforts going on. No question about it. Beyond that, it gets a little fuzzy. How much of an impact did [any particular intervention] have and which things actually were critical to making the ACA happen?”

This last statement, with its combination of broadly conceived certitude and localized indeterminacy, epitomizes one of this report’s central findings regarding the claims of philanthropic impact. (Case Study, Pg. 4)

Dr. Soskis’s study also examines the difficulty of disentangling the impact of any one funder from the impact of philanthropy as a whole. He writes:

In fact, disaggregating the specific contributions of particular philanthropic funders and determining how to weigh them against each other proved one of the most significant challenges of this project. This would be an issue for any major policy initiative, but for national [health care reform], given the large number of funders involved and the efforts to coordinate activities between them, it proved even more challenging. This suggests one of the main paradoxes of evaluating the impact of philanthropy on the passage of health care reform legislation. Precisely those features which many considered essential to the passage of the ACA – the breadth, variety, and scale of philanthropic initiatives – also made it especially difficult to evaluate the contributions of any particular intervention. And the report highlights another paradox as well, one which presides over the entire study of policy impact evaluation: the more significant the legislative achievement, and the greater the impulse for various stakeholders involved to claim a definite degree of impact, the less likely it is that any determination of clear causal agency is actually possible. (Case Study, Pg. 4)

Read the full case study here (.pdf)

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