Robert Ross

Major shifts in the U.S. health-care system have transformed many nonprofit institutions into business enterprises. In May 1996, for example, the nonprofit insurer Blue Cross of California became a for-profit company, WellPoint Health Networks. In agreement with the state of California, the new corporation gave $900 million in cash to the California Endowment and a substantial portion of WellPoint stock to its sister organization, the California HealthCare Foundation.

The California Endowment, currently with assets of $3.7 billion, is the largest private health funder in the state and is dedicated to helping the underserved gain access to affordable quality health care. To date, it has awarded 1,580 grants, totaling about $559 million, to community foundations, universities, neighborhood care providers, affordable-housing developers and foster-care and family-services groups. In the L.A./Orange County area alone, the Endowment has awarded $86 million through 436 grants. Together with the Bill & Melinda Gates Foundation (assets $21 billion) and the David and Lucile Packard Foundation (assets $13 billion), the California Endowment makes the West Coast home to some of the nation’s largest--and newest--philanthropic funders.

But since its inception four and a half years ago, the Endowment has been in turmoil. Two CEOs have come and gone, and critics charge that the Endowment still acts like a start-up organization and that its grant-making criteria are vague. Enter Robert K. Ross, who became the third president and CEO in July.

Described by some as a “visionary,” Ross, a pediatrician, has a solid reputation as an advocate for expanded health care access to children, the disabled and underserved minorities. Previously, he was director of the $1.2-billion Health and Human Services agency for San Diego County and is credited with having overhauled and integrated various departments under a single public health umbrella. Ross believes that as “Los Angeles proceeds with dealing with [health] challenges, California will follow, and as California proceeds, the rest of the country will follow.”

Ross received his bachelor’s, master’s in public administration and medical degrees from the University of Pennsylvania. He, his wife, Robin, and two of his three children reside in Woodland Hills.

*

Question: How do you answer your critics?

Answer: A lot of the criticisms are appropriate but also expected. This is an organization that may not be in its infancy, but may be in its toddler stages in terms of development. By large-foundation standards, we are still a young organization. So it is not surprising that we have been somewhat broad in our grant-making and focus.

*

Q: What is your focus now?

A: The issue of disparities in health care and health status [is] a major area of emphasis. It includes strengthening and expanding some partnerships that we have undertaken with the Centers for Disease Control and Prevention in Atlanta under a “REACH [Racial and Ethnic Approaches to Community Health] 2010” initiative, which has to do with ethnic approaches to improving health status. We’ve allocated some funding to allow community-based partnerships to identify health issues [associated with] significant health-status gaps in communities of color. There’ll be a minimum of five such communities throughout the state of California, [and] Los Angeles will be part of that contingent.

*

Q: The California Endowment talks about multicultural health care. What does that mean?

A: This is perhaps the most diverse state in the world. California, as it attempts to address some of the disparities in health, in particular, in communities of color, in the poor and rural populations, does not have the luxury of sitting back and waiting for innovative models and approaches to be developed elsewhere [in the United States]. . . . For example, we have a three-year, $1 million grant at White Memorial Medical Center in Boyle Heights. [The money funds] a program [to develop] a curriculum of cultural competence for faculty and residents. When you ask me what does cultural competency mean, my answer is: We are still developing the definition and standards for how that translates into practice guidelines, into what kinds of education medical residents and interns ought to receive, what kinds of linguistic and translation capabilities health institutions ought to have at their disposal. So that’s part of our investment: developing a standard and a definition for cultural competency so it doesn’t sound like liberal babble-speak.

*

Q: Where has cultural competency been achieved?

A: Our intuition is that because community clinics have for decades served the needs of the poor and the underserved and, in many cases, predominantly communities of color, they have far more experience than traditional health institutions like hospitals. . . . We are engaged in a lot of grant-making to support community clinics. In fact, that is a major point of emphasis in our grant-making for the next four years. We hope to take some of what the [clinics] have learned in terms of culturally appropriate responses in health-care delivery and apply those lessons to hospitals, larger clinics and health maintenance organizations.

*

Q: Are you saying there is a connection between what’s going on in health care at the community level and changes that should occur at the institutional level?

A: Yes, I think part of what has become the philanthropic mantra is this notion of community-based action, and it wasn’t just the California Endowment. Philanthropic literature is replete with the community-based [idea]. There is no question that the incubator for innovation is generally at the community and neighborhood levels, and with nonprofit community-based institutions. . . . For many of the large-scale institutions, HMOs and university settings, their job is to take the innovative ideas that have been brewing up from communities and neighborhoods and study their effectiveness. And then, if they work, implement them on a larger scale.

For example, a researcher at the University of California at San Diego was looking at awareness of breast cancer in women of color. She concluded that in the African American community, for example, a key informant that could play a critical role in breast-cancer awareness were beauticians. When I heard that I said, of course. My mother used to go to the beauty parlor every other Saturday for three or four hours, and she had a very trusting, important relationship with her beautician. So the thought of using a beautician to steer the conversation toward breast-cancer awareness and early detection and mammography and self-examination was elegant in its simplicity.

In the Asian community, the researcher found that the key informant would be the Asian grocer, because many of the women not only shop at Vons and Ralphs; to prepare their ethnic meals, they go to ethnic-specific Asian markets and have a trusting relationship with the Asian grocer. What are the implications for that kind of breast education or awareness for the Centers for Disease Control and Prevention, for Kaiser Permanente, for Blue Cross? If, in fact, we are trying to not only improve on health status but to be more cost effective in our approaches, then prevention is going to be the horse that is going to get you there. And looking to the community for those kinds of innovative, out-of-the-box prevention and awareness approaches are going to be critical

*

Q: Because government has withdrawn from many activities, foundations have often stepped into the breach and funded model programs. In a state as large as California, how do you expand these models to a scale that actually addresses the problems?

A: You just asked the $64-billion question in philanthropy. This notion of funding innovative pilots and ideas is pervasive in the philanthropic industry. You provide someone with a three-year grant, the grant goes away, the model goes away, the innovation goes away. You’ve ended up perhaps causing even more harm, because you’ve raised the expectation of the community being served by that pilot. There are some areas where philanthropy ought to play a more significant role, not just at the level of grant-making, but at demonstrating leadership at the policymaking level to turn the successful pilots into large-scale meaningful change.

Consider the number of uninsured children in the state of California. Our best estimates are that there about 2 million of them. We believe that approximately 1.5 million of them are eligible for some existing program, be it MediCal or Healthy Families. There have been some models that successfully reached out to these kids and families and got them signed up for coverage. Why is it that in year 2000, we still have a million-and-a-half uninsured Californian kids? And why can’t we find these kids on a large scale? I believe this is an area where philanthropy in California needs to act less like a teddy bear and more like a grizzly bear.

Can we partner with other foundations and engage the policymakers and say, “Look, the community has demonstrated that they know how to do this. Here are some models. what is it going to take to get there?” Perhaps, [philanthropy] has been a bit too polite in not throwing our weight around on certain issues.

*

Q: What are your other priorities in the policy area?

A: Philanthropy needs to weigh in on the health issues facing farm workers and their families, both from a moral standpoint and a policy standpoint. These people are helping to feed the state and perhaps feed this nation. Many of them are here illegally, and they’re invisible to public programs in terms of public-health services. But the stark reality is, they’re here and they’re here in large numbers and they’re important to the economy. The public policy around public-health care has not caught up to the stark reality of their health status. For years, since Cesar Chavez, we’ve known that farm-worker health is something that needs to be addressed. Decades have gone by and we’re not much farther along than we were then.

*

Q: The Endowment has a commitment to a diverse work force in the health-care industry. What does that have to do with people’s health needs?

A: There are differences in cultural understanding that make a very significant difference in the health outcome of a child, of an adult, of a family. This phenomenon is most strikingly captured in the book “The Spirit Catches You and You Fall Down.” For example, when I was a pediatric intern in Philadelphia, a wave of Hmong had resettled there. I was covering the emergency room late on a Saturday night. A 2-year-old child with a high fever came in. His parents couldn’t speak any English, and we had no translator in the emergency room. I examined the child and discovered he had an ear infection. But when I started to listen to his chest, I noticed that he had red streaks across his back, which in my world view look like belt marks. I couldn’t associate them with any other phenomenon other than a beating. I asked the parents about it and, of course they looked at me quizzically, because we couldn’t communicate.

I ended up calling the Child Protective Services agency. Fortunately, the senior resident, who was on call in the emergency room, ordered me to put the phone down. He told me that my “belt marks” were something called coin-rubbing, a Hmong ritual to relieve a child’s fever or get rid of an illness. Those kinds of interactions between family and provider, in part, are responsible for and explain some of the health-status gaps and disparities that still exist. Whether you’re an African American with diabetes or an Asian woman with cervical cancer, those issues are best addressed with an enhanced cultural understanding of what the issues are.