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How We Work: The Commonwealth Fund’s Approach to Health System Change


The Commonwealth Fund enjoys the enormous privilege of stewarding a charitable endowment established nearly 104 years ago. We think every day about the responsibility this privilege conveys: to make our resources count by promoting a high-performing health system that provides affordable, high-quality care to all Americans, especially for the most vulnerable among us; and to confront the racism that has so deeply injured people of color in our health care system.

Of course, these responsibilities are easier felt than met. The U.S. health care system is almost unimaginably large. If it were a separate country, it would have the fifth-largest gross domestic product in the world. Every minute of every day, it spends twice the Commonwealth Fund’s $46 million annual budget. Change is always hard, but it is especially so in a system as huge, entrenched, complex, decentralized, and politically fraught as the American health care system. No other country in the world has a health system as difficult to govern, reform, or improve.

To tackle this enormous challenge, the Fund has one weapon: information. As a private foundation, we do not lobby, write legislation, or take explicit positions about issues. We don’t engage in political activity of any kind. We support — through intramural and grant-funded work — the generation, collection, and dissemination of objective evidence about the state of the health care world, and policies that might improve it. So the issue we face every day is how to work with our many grantees and collaborators to make information a powerful tool for progress.

This challenge has focused and sharpened our thinking. It has forced us to examine how reform happens, what role information plays in that process, and how the information we help to generate can be used to maximum benefit.

The strategy we have chosen starts by trying to understand reforms that would significantly improve the performance of our health system, and thus the health and care of Americans, with special attention to improving health equity and combating racism. In this process, we depend on the wisdom of a vast array of experts from all corners of our health care system, as well our board of directors and staff. Through these consultations, we identify overall Fund priorities such as increasing the number of Americans with good insurance coverage, controlling health care costs, promoting value-based payment, and identifying policies that would expand health equity. In each of these areas, we set specific yearly and multiyear goals for the improvements we hope to accomplish, and we develop ways to measure progress.

Next, we identify actors whose decisions could move us meaningfully toward these goals, as well as the information that might help them make the best possible decisions. Here again, we rely on the advice of a diverse array of expert informants, grantees, and collaborators for guidance. We are particularly attuned to pinpointing deadlines or events that might force or encourage these actors to make such decisions.

Potential change-makers are generally, but not exclusively, actors with the capacity we lack on our own — the ability to effect positive change at scale in our health care system. They include government officials at the federal and state levels, leaders of health care organizations, health care professionals, opinion leaders in society, and the media. Potential deadlines or events might involve pending legislation or regulations at the federal or state level, Medicare’s focus on value-based payment, or the progress of a particularly important case through the courts. We recognize, of course, that all of us as individuals make critical decisions about our own health and health care, too. But we believe that our relatively limited resources are best directed toward those whose actions can produce systemic change — as opposed to, for example, a public information campaign aimed at shifting popular opinion.

We realize that almost every actor in our health care system faces enormous time constraints as they juggle complex and demanding daily challenges. Information presented at the wrong time or in the wrong way may have little impact, but when advanced at another time or in another way, that same information might be extremely influential. Therefore, we aim to generate and present the right information, at the right time, to the right people, in the right way. Success in this endeavor requires a great deal of planning, flexibility, and collaboration, both within the Commonwealth Fund and with our grantees, who generate much of the information that can further our goals. Constant communication among grantees, outside informants, and our staff is critical to success.

The strategy I’ve described above — focused on informing important decisions in a timely way— is by no means the only approach a philanthropy like ours could choose to make change in the health care system. There is great value, for example, in supporting fundamental investigation in both the biomedical and health services fields, with the expectation that this will yield important advances in health and health care over the long term. There is also great value in investing in human capital to train leaders who have the skills and commitment to move our health care system forward. Indeed, the Commonwealth Fund supports a number of fellowships and some research investigating basic questions about the health care system’s behavior. In the end, we believe that the Fund’s change strategy makes effective use of our resources and complements the work of many other private and public funders who make longer-term investments.

We think it important that our grantees and other external partners understand how we go about our work. Some will find our approach energizing, others overbearing. We hope for the first reaction but understand the second. One reason for writing this post is to help grantees know what to expect when they work with the Commonwealth Fund and, I hope, facilitate a dialogue with our partners and grantees that improves our work.

Philanthropies have a responsibility to think hard and strategically about using their resources to the best advantage. In that process, they also have a responsibility to remain humble and open to advice from their partners and grantees and to continually reexamine how they pursue their goals. We hope this brief account of our current approach to improving health system performance will lay the groundwork for a continuing dialogue about the optimal ways for the Commonwealth Fund to promote the common good.

Publication Details



David Blumenthal, Former President, The Commonwealth Fund

[email protected]


David Blumenthal, "How We Work: The Commonwealth Fund’s Approach to Health System Change," To the Point (blog) Commonwealth Fund, July 27, 2022.