How The Robert Wood Johnson Foundation Has Influenced Health Policy – And My Own Life – For Five Decades
Forbes | March 16, 2023
Bill Frist, Contributor
Private foundations in America play a unique and vital role in advancing social progress. That is well known. What is less recognized is the impact such Foundations have on individuals who work within them. This story is a personal one.
In January, I completed a decade of service on the Board of the Robert Wood Johnson Foundation, America's largest philanthropy devoted to health. While many Americans may not be familiar with this organization, it has made a major impact on U.S. health policy and on the health of all Americans. More personally, it has transformed my own life and thinking as well.
Understanding the Impact of the Foundation
My experience with the Robert Wood Johnson Foundation (RWJF) began in 1975. Almost 50 years ago, it was my first time in the RWJF board room. I was accompanying Anne Somers, professor, healthcare expert, and co-author with her husband Herman Somers of the classic Doctors, Patients and Health Insurance: The Organization and Financing of Medical Care. I had spent a year with her while a student at Princeton, assisting with research in updating her book.
Entering the striking new Foundation building, I was in awe of the place. I met Gustav O. Lienhard, the storied Chairman of the Board of Trustees, who had served for years at Johnson & Johnson with CEO Robert Wood Johnson, and was personally selected by Mr. Johnson to head the Foundation. The Foundation had been “propelled to full growth” as explained in its 1972 annual report, transitioning from a local philanthropy to one of national importance nearly overnight as Mr. Johnson left a bequest of over 10 million Johnson & Johnson shares (valued at about $1 billion) to launch the Foundation to new heights. The report explained, “The Robert Wood Johnson Foundation’s resources represent the largest single source of private capital to support new efforts in the health field.”
Though then just a first-year medical student, I began to understand the unique and major role that foundations, private and public, play in society—the financial resources, the long-term focus, the bridge between the private and public sectors for societal change, and the high standards of accountability and transparency. But I wouldn’t realize until years later the role this specific foundation would play again and again throughout my life – influencing the policy I introduced in Congress, inspiring the model for a palliative care company I co-founded, and igniting the need for change in my own community.
Transplantation and Tobacco Cessation
One of the earliest intersections of RWJF and my life occurred when I was a heart and lung transplant surgeon at Vanderbilt. In the mid-1990s the Foundation launched a nationwide program called the National Program for Transplantation which aimed to expand access to transplantation and improve the quality of care for transplant patients. I was struggling in my daily life as a transplant surgeon with the very issues the Foundation had stepped in to address and lead on nationally. In 1989 I had founded the Vanderbilt Multi-Organ Transplant Center, and we began transplanting organs that we newly had the science to transplant. Multi-organ transplantation was in its infancy. Evolving clinical and social challenges would present daily in this fast-evolving medical field. I had written a book called Transplant: A Heart Surgeon’s Account of the Life-and-Death Dramas of the New Medicine on these same issues arising from a critical organ donor shortage for the many thousands of people who could then benefit from transplantation. Two decades into building a platform to engage in major health challenges of our time, the Foundation had quickly demonstrated its currency, relevance, and willingness to take on current and emerging issues, such as organ transplantation in the 1990s.
And in 1991 the Robert Wood Johnson Foundation began to tackle one of the most intractable problems in the field of public health — tobacco addiction, beginning a 20-year campaign that invested nearly $700 million in efforts to prevent tobacco uptake, especially by children, and to help addicted users quit.
Once again, it was personal for me. As a cardiac surgeon, the most common procedure I was performing each week was coronary artery bypass grafting – opening the chest, stopping the heart, grafting pieces of vein to bypass or jump over the diseased portions of heart arteries. And smoking was among the strongest of all contributors to causing the disease that I was operating on each day; heart disease was the number one cause of death in the U.S. So RWJF focused its vast resources on reversing this disease.
Influencing Federal Policy
I carried my operating room experiences and learnings from RWJF’s advocacy into my next career. I was elected to the United States Senate in 1995, and as the only physician serving in that body, I naturally gravitated to health issues. This brought me back to the Board room at RWJF to discuss an issue they had been so powerfully leading on.
It was 1998, and I was working closely with Senator John McCain (R-AZ) on legislation to allow the FDA to regulate tobacco for the first time, giving the agency the authority to require the disclosure of product ingredients, change warning labels, incentivize safer products, and restrict the marketing and sale of tobacco products to children. It may seem unimaginable today, but then the tobacco industry was unregulated, and we were trying to change that. The team at the Robert Wood Johnson Foundation had become the national experts in tobacco cessation and had been the financial impetus behind much of the positive national change in reducing smoking. Their advice and counsel were crucial to our efforts.
Despite our committed push then, the Senate wasn’t ready for this next step in furthering public health. It wasn’t for another decade, in 2009, when Congress finally acted, and the FDA received the authority to regulate tobacco. But McCain and I set the stage with our 1998 bill, much of which was included in the 2009 Family Smoking Prevention and Tobacco Control Act, and RWJF was a vital partner in that effort. Indeed, the RWJF investment was central to turning the tide on tobacco addiction in America. Data demonstrated millions fewer smoking in 2010 compared to the 1990s, and smoking rates dropped from over 25% in 1990, to 19% in 2010, with latest figures showing 12.5% in 2020. And parallel to that we have seen a dramatic fall in deaths from heart attacks (a decline of about 87 deaths per 100,000 people in 1999 to about 38 deaths per 100,000 people in 2020) and cardiovascular disease including stroke (stroke mortality per 100,000 declined from 88 to 31 for women and 112 to 39 for men between 1975 and 2019 in the United States).
I served as Senate Majority Leader from 2003 to 2007, and for much of that time I continued to be the only Senator with a medical background. In that capacity I firsthand witnessed yet another defining and far-reaching program of the Foundation – the Health Policy Fellowship. RWJF smartly recognized the need for more medical experience at the highest levels of government. Thus, this program, familiar to all in DC, sends mid-career health professionals to work in Washington as policy fellows. They are placed in a range of government agencies, Congressional offices, and think tanks to gain direct experience in shaping health policy at the national level. Indeed, I was lucky to have RWJF Fellows serving on my own health-related Congressional committees. The Fellows program has produced a generation of leaders who effectively bridge the gap between policy and health delivery, integrating skills and experience to improve health for all.
Defining the Field of Palliative Care
RWJF never rested on its laurels and was always looking for the next big public health challenge to take on. On the heels of its tobacco work, beginning in 1996, the Foundation embarked on a 15-year effort to improve end-of-life care. It essentially defined the field of palliative care in America.
At the time, studies found most Americans in the 1990s died in hospitals, often hooked up to machines or in the ICU, and in many cases at odds with their wishes to die at home with family. For too many the last several months of life were chaotic, confusing, and frightening. In 1997, RWJF initiated the Promoting Excellence in End-of-Life Care program to identify, promote and institutionalize care practices that allow seriously ill people and their families to approach the end of life in physical, psychological, spiritual, and emotional comfort. It funded 22 demonstration projects creating new models of palliative care, four demonstration projects that tested models of delivering palliative care within hospital ICUs, and created the Mount Sinai School of Medicine Center to Advance Palliative Care. Moreover, it developed the initial framework for physician specialty training and certification in Palliative Care.
This progress and advancement of the field of end-of-life care dramatically affected my life 20 years later – and through that ultimately the lives of scores of thousands of others across the country. During the early 1990s I was running the Transplant Center at Vanderbilt and weekly performing heart and lung transplant procedures. Patients referred to us for transplantation had a terminal diagnosis (until eventually transplanted); thus, I became deeply involved in managing the care of individual patients at the end of life, as they waited weeks and months for a donor organ to become available. I saw that with a dedicated team-based approach that included the family, patients could live a much higher quality of life, even with a terminal diagnosis. RWJF’s palliative care models validated with data my own personal experiences, demonstrating the need at scale for this type of multi-discipline, team-based care for those with serious and terminal illnesses.
After leaving the Senate in 2007, I had the opportunity to consider this need more seriously. I and colleague Brad Smith, whose brother was a palliative care doctor, observed that palliative care was readily available in urban areas close to large teaching hospitals but not for patients in suburban and more rural regions. It was an access issue – an equity issue. And we set out to help solve it.
Using the Robert Wood Johnson Foundation model, in 2013 we co-founded and subsequently grew the community-based, palliative healthcare company Aspire Health, which expanded to 34 states within three years, serving thousands of people in suburban regions who would not otherwise have that life-changing care. Aspire became the largest non-hospice, community-based palliative care company in the nation, taking to scale learnings from the Robert Wood Johnson Foundation models. We worked directly with Mount Sinai leadership. This story is an example of how private foundations in our country play such a unique role in synergistically bringing the private and public sectors together to the betterment of humanity.
Commission to Build a Healthier America and Social Determinants of Health
In the years between leaving the Senate in 2007 and building Aspire, I engaged in my first substantive volunteer project with the Foundation. I received a call from my friend Dean Rosen, who was working with the Foundation in DC, and he asked if I would consider spending time on an exciting, upcoming project with RWJF that would focus on how a community affects an individual’s health. It would center on the non-medical determinants of health – now called the social determinants of health.
From February 2008 to December 2009, I served on the Foundation’s Commission to Build a Healthier America, chaired by former CMS Administrator Mark McClellan and former Director of the White House Office of Management and Budget Alice Rivlin. Led by then-Commission staff director and Harvard Professor David Williams (currently on the Board of the Foundation and chair of the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health), we were joined by 12 brilliant and diverse thought leaders who challenged the status quo on health and healthcare. Together we looked outside the system for ways to improve health for all, ultimately issuing 10 substantive recommendations for action.
Today, social determinants are a regular part of our health and wellness vernacular, but 15 years ago, we were just scratching the surface of the issue. Few realized that social determinants drive as much as 80 percent of health outcomes. This was the first time social determinants as a field were comprehensively defined; we realized that where you live, work, play, and pray had a greater impact than your doctor. We popularized making the healthy choice the easy choice. While we are still grappling today with how to address and incorporate these external factors in our traditional healthcare systems, RWJF’s Commission once again pioneered the way in changing the dialogue.
And we build on this new understanding in so many ways today. For example, in my current position founding and building healthcare companies in the private sector (with Cressey and Company and with Frist Cressey Ventures) to help solve the needs of vulnerable populations, we place a special emphasis on social determinants, for example food (Mom’s Meals), digital access for the underserved (Thrive Health), community services at home (CareBridge), and home accessibility for those with disabilities (Lifeway Mobility).
$1 Billion Dollars to Address Childhood Obesity Epidemic
After my many influential experiences with RWJF, I committed to joining its Board of Trustees in 2013. The Foundation typically takes on the really big issues of our time. One of its major issues of focus had become our nation’s crippling, childhood obesity crisis. In the early 2000s, childhood obesity had reached epidemic proportions, and in 2007 the Board committed $500 million to fight this phenomenon, with a goal to reverse the epidemic. In 2015, we as a Board committed an additional $500 million (for a grand total of $1 billion dollars) over 10 years to continue the bold initiative. Learnings from this work have dramatically influenced federal policy on school meals, food assistance, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
Inspiring Community Action in Nashville
My time on the Board informed and inspired my next community venture in real time. As a Nashville native, I’ve long taken pride in my city’s national leadership in the field of healthcare services; it was, at the time that I joined RWJF, home to 17 publicly held healthcare service companies with national reach. These companies would routinely receive awards for their outstanding quality of care delivered around the country.
But my eyes were widely opened one afternoon when our Foundation’s initiative to build data resources around county-level health outcomes was being presented. Far from the outstanding quality I had assumed, I learned we in Nashville had embarrassing health disparities and overall poor health. Despite our rich local healthcare resources, Nashville had higher rates of obesity, higher rates of infant mortality, higher smoking rates, and higher rates of hypertension compared to all our peer cities. A fellow board member asked me why this was, and I honestly didn’t have the answer – but from that day forward I became committed to figuring it out.
Drawing heavily on what I had learned from my participation on the Foundation’s Commission to Build a Healthier America, in 2015 I brought together our city’s healthcare executives, non-profit and faith-based leaders, community activists, and local elected officials to form a community-based collaborative dedicated to moving the needle on Nashville-Davidson County health measures. We launched NashvilleHealth, and today, now eight years later, it continues to forge innovative partnerships to advance health equity in our city.
In 2019, this unique collaborative conducted the first countywide health assessment in nearly 20 years. Then, following the pandemic in 2021, NashvilleHealth comprehensively evaluated our city’s response to COVID-19 and issued 28 actionable recommendations for future public health preparedness and crisis response readiness. And it helped plant the seeds for the now burgeoning, statewide data collaborative recently launched at Belmont University just last year. This movement is all thanks to that original data gathered, analyzed, and publicly shared in the RWJF County Health Rankings that made clear the need for action.
RWJF: The Next Ten Years
My term on the Board has expired and another will fill my place. As I look back on the last decade of service, and on all the Robert Wood Johnson Foundation has accomplished in that time and in the years before, there is no question this organization has been a force changing for good the trajectory of health and wellbeing in America. It has also been, as I have shared, a force for good in my life, shining a light on where new health policy, community action, and private sector healthcare innovation can be so valuable.
The Board has demonstrated a wise strategic direction over the years, and I know that will continue. It is not my place to advise at this point, but I do have a personal hope. It is that the Foundation does consider in the future what the World Health Organization (WHO) has called “the single biggest health threat facing humanity.” That threat is climate change. The Foundation has always been ahead of the curve in tackling our most significant barriers to health, and the reality of a changing climate and extreme weather events is in my mind among the greatest challenges to health before us.
I look forward to seeing the change RWJF will make possible over the next ten years.