Over the past 30 years, as the U.S. health system fell ever further behind those of other developed democracies in terms of outcomes and cost, every reasonable observer knew that the basic cause was our country’s disgraceful lack of a government guarantee of health care for all. Yet, during these same decades, most health care grantmakers ignored this elephant in the room by funding mostly service provision instead of the kind of advocacy that would make enactment of government-guaranteed health care more likely.
Finally, toward the end of George W. Bush’s second term as president, a group of labor leaders, nonprofit leaders and philanthropists realized that a number of factors had created a once-in-a-generation opportunity to finally enact health care for all, including:
The reformers seized this historic opportunity, coming together as Health Care for America Now (HCAN) in 2008. HCAN grew into a mighty coalition and made history by playing an indispensable role in enactment of the biggest progressive reform in a generation: the Patient Protection and Affordable Care Act of 2010 (ACA).
Richard Kirsch tells this amazing story in his recently published Fighting for Our Health: The Epic Battle to Make Health Care a Right in the United States (Rockefeller Institute Press, Albany, 2011). This book is the best account of the biggest domestic reform in a generation. Kirsch is uniquely well qualified to tell the tale; he is a gifted writer, one of the nation’s foremost health care advocates with decades of experience. As founding executive director of HCAN, he not only witnessed every twist and turn in this “mother of all political battles,” he also played a key role in leading the grassroots army that out-mobilized the Tea Partiers while pressuring and cajoling federal lawmakers to finally take care of, in the words of former Senator Ted Kennedy, “the great unfinished business of our society.”
Here are the types of readers who must devour this book right away – and why:
Practitioners and students of American politics will learn every aspect of how a major reform bill becomes law: conception, drafting, messaging, coalition-building, grassroots lobbying, earned and paid media, direct lobbying, etc. They will witness the fascinating (and sometimes unseemly) process by which Congress and the White House grind the legislative sausage. And they will enjoy the perfect thumbnail sketches, some in acid, of many of our nation’s most powerful leaders.
Nonprofit advocates (and those contemplating a career as such) will learn the joys and sorrows of this type of public service from Kirsch’s description of his long career as an organizer culminating in leadership of HCAN. From the detailed description of HCAN’s inner workings, they will see how to conceive and execute a model campaign. I hope advocates notice in particular HCAN’s wise decision to make authentic grassroots organizing the centerpiece of the campaign – as opposed to the all-too-frequent dependence on paid media or parachuting Beltway operatives into localities to try to fake grassroots mobilization with “Astroturf” actions.
This brings me to the final audience that must read this book: grantmakers. Obviously, health grantmakers will be curious to learn how the biggest step forward in U.S. health care in generations actually happened. Kirsch’s book will show them how funding advocacy gets better return on investment than funding service provision. And they will learn how to fund advocacy by observing the wise decisions of HCAN’s biggest benefactor, the Atlantic Philanthropies, which invested approximately $26.5 million in HCAN over several years. Consisting of 501(c)(4) dollars, Atlantic’s investment was complemented by 501(c)(3) grants from other funders, notably the California Endowment, to the HCAN Education Fund. All these investments in HCAN are arguably the most effective philanthropy in a generation in terms of return-on-investment. Hopefully, health grantmakers will act on these lessons right now by investing to ensure that ACA gets implemented properly. HCAN continues to do great work on implementation (and other issues). And there are many other opportunities right now at the national and state levels to fund ACA implementation, documented in a recent NCRP report and NCRP’s archived January 24th webinar on this topic.
Not only health funders, but indeed all grantmakers, should read this book, for it teaches many general philanthropic lessons, including:
What would happen if more grantmakers heed the lessons of HCAN? The U.S. would have more permanent progressive nonprofit infrastructure that could quickly form coalitions to exploit opportunities for reform to benefit underserved communities. This same infrastructure would be strong enough after elections to hold lawmakers accountable.
Lawmakers to be held accountable include Democrats. Too many liberals – grantmakers included – still seem to believe that if Democrats win an election, then progressive reforms happen automatically. Kirsch’s book shows once again that this is poppycock. Semi-corrupted by the campaign finance system and the revolving door to K Street, Democratic lawmakers never, of their own volition, live up to their stated principles by voluntarily enacting the progressive reforms they espouse on the campaign trail. There is only one thing that can oblige them to do so: strong and permanent progressive grassroots infrastructure that cajoles, encourages, lobbies and pressures them round-the-clock.
Lest readers think I am picking only on current Democratic lawmakers for their dilatory performance in enacting ACA, just ask yourself a simple question: Would LBJ have enacted the Civil Rights Act and Voting Rights Act without a militant civil rights movement pressuring him from the streets? And even my personal hero, FDR himself, once admitted to a group of progressive reformers, “I agree with you. I want to do it. Now make me do it.”
What else but permanent, strong progressive nonprofit infrastructure can “make them do it”? What else can help regular Americans (the 99%) offset the overweening power of the multinational corporate special interests (now stronger than ever thanks to Citizens United), an increasingly hard-right GOP, and a Democratic Party semi-beholden its big campaign donors?
My only quibble with Kirsch’s book is this: he never explains why Democrats did not choose to pass the bill in the Senate via simple majority using Rules of Reconciliation instead of allowing Republicans and a handful of conservative Democrats to hold the bill hostage for months and months with filibusters (and the mere threat thereof). As ACA clearly would have helped close the budget deficit, why could it not be passed via reconciliation?
But that is just a nitpick. Stop what you are doing, buy this brilliant book and read it – especially if you are a grantmaker.
Sean Dobson is the field director for the National Committee for Responsive Philanthropy.
 See Terri Langston, Towards Transformative Change in Health Care: High Impact Strategies for Philanthropy (Washington, D.C.: National Committee for Responsive Philanthropy, April 2011).
 Sean Dobson, “A Number Every Grantmaker Should Memorize: 0.1%,” Keeping a Close Eye …, September 26, 2011.
 See http://healthcareforamericanow.org/.
 See Langston.