“Evidence to Action.” The Commonwealth Fund’s Evolving Approach to Healthcare Equity

Everything about Dr. Joseph Betancourt’s background made him a perfect fit for the job he now holds — president of the Commonwealth Fund.

Born in Puerto Rico and raised in New York City, he says that like the many patients he has served as a primary care doctor, he “grew up in a bilingual, bicultural home, having a family who certainly struggled with healthcare.”

His experiences, along with coming from a family that was also committed to activism around the needs of people with no voice, led him to pursue a career focusing on “how we could improve care for everyone and leave no one behind.”

Betancourt got a strong foothold to move in that direction, he said, when, in 1997, he became a fellow in the second cohort of one of the fund’s anchor programs, the Commonwealth Fund Fellowship in Minority Health Policy at Harvard. The program is aimed at bringing more people of color into decision-making roles in healthcare. Fellows in the program earn master’s degrees in public health and health policy management and receive leadership training and mentoring from national healthcare leaders.

“So in one year, you're really able to develop almost seven to 10 years of networks, contacts, expertise,” said Betancourt, who took over the helm of the Commonwealth Fund around 15 months ago. “And it fundamentally changed my life.”

The reasoning behind the launch of the fellowship program, which has graduated 150 fellows to date, was to “build in rather than bolt on” leaders from diverse backgrounds to the healthcare system, Betancourt said.

That focus is aligned with the Commonwealth Fund’s overall mission: “to promote a high-performing, equitable healthcare system that achieves better access, improved quality and greater efficiency, particularly for society’s most vulnerable.”

A century-old field-shaper with 21st-century aims

The Commonwealth Fund was founded by Anna Harkness in 1918 with $10 million drawn from the estate of her late husband, who had made his fortune investing in Standard Oil. According to the Commonwealth Fund’s earliest available tax form in 2001, it paid out more than $15,349,000 toward grants. Its most recent tax filing from 2023 shows that it paid out $28,618,000 in grants that year. That’s nearly double what it was paying out back in 2000.

From the start, the foundation invested in public health prevention, helping to create maternal-child health departments and supporting immunization programs for children around the country, according to a video commemorating the fund’s centennial.

The Commonwealth Fund was also a forerunner in building modernized rural hospitals in the 1930s and 1940s, which served as models for a federally funded program passed into law in 1946 to build hospitals all over the country, according to John Craig, a former executive vice president and chief operating officer. “This was a huge impact for a foundation our size,” Craig said in the video.

Similarly, with its focus on evidence-based prevention, the Commonwealth Fund has funded research that helped launch and expand public health programs around the country. One example is the foundation’s Healthy Steps initiative, which began in 1995, and since 2015, has been run by the national nonprofit Zero To Three. The program trains specialists who work in doctors’ offices and supports families to ensure their infants meet developmental milestones. Healthy Steps, which started with two demonstration sites, has since expanded to 261 pediatric primary care sites around the country.

As part of its work to promote access to healthcare, the foundation supported research to highlight the value of health insurance and the problems faced by those who lacked coverage over the decade, according to Melinda Abrams, the fund’s executive vice president for programs. “I think a lot of that research contributed to evidence that informed the development of the Affordable Care Act,” she said, referencing the federal program passed into law in 2010.

Such an approach reflects the Commonwealth Fund’s theory of change for producing the greatest impact — provide evidence to decision makers, Abrams explained. As another example of this approach, to inform federal healthcare agencies and the incoming government in 2021, the fund assembled a taskforce of experts to analyze the healthcare delivery system’s previous decade and weigh in on what worked, where it fell short and to offer suggested remedies. Among the report’s recommendations that have since been adopted, according to Abrams, are that doctors’ earnings be tied to patient outcomes and quality of care, a system known as value-based care, and that health systems develop equity action plans.

Moving from evidence to action on health equity

The fund’s work on advancing health equity is one of its largest program areas, according to Betancourt. A cornerstone of its work is the fund’s state scorecard on health disparities, which it has been conducting for about two decades. The scorecard tracks such things as preventable deaths, adults who went without care because of the cost, and avoidable emergency department visits by race and ethnicity. Among the conclusions reached in the Commonwealth Fund 2024 State Health Disparities Report was that “deep-seated racial and ethnic health disparities persist across the United States, even in states with otherwise high-performing health systems.”

Betancourt said he would love to build a collaborative that included states that the scorecard showed were low-, middle- and high-performing, so they can “share and engage. That to me is moving from evidence to action.”

Maternal health also falls within its advancing health equity work, said Betancourt, “given the very significant maternal health disparities that exist, particularly for Black women.” Another project in advancing health equity is the fund’s support for a collaborative of hospitals in Chicago, which have developed a tool to measure disparities and progress in meeting their goals. “Our approach with equity and healthcare is really to figure out ways in which we could thread equity through all of the healthcare activities that are happening nationally around affordability, access, quality and safety,” he said. (Find out more about the fund’s other program areas here.)

In light of the large-scale, systemic focus of the Commonwealth Fund’s work — which also includes researching, tracking and improving policies around Medicaid, reducing medical debt and healthcare costs — it often partners with other foundations. This includes working in the area of disability with the Robert Wood Johnson Foundation, with the Milbank Foundation on primary care, with the John A. Hartford Foundation, the SCAN Foundation and the Peterson Center on Healthcare on the needs of older Americans, and with the California Health Care Foundation on health equity.

Looking ahead to next year, Betancourt said, the team’s still in an exploratory phase but are looking to deepen some of their existing work. One such area: primary care and value-based payments. Another: affordability. “I think our nation has done a phenomenal job around increasing healthcare coverage.” But, Betancourt said, there are lingering problems with affordability and the foundation wants to identify challenges and solutions.

The Commonwealth Fund is also interested in what Betancourt called “the commercial drivers of healthcare.”

“There's no doubt that private equity, consolidation of hospitals, are leading to what many people are feeling is a greater focus on profit and revenue over patients,” he said, explaining that the foundation wants to use its evidence-based approach to better focus on the issue of private equity.

Another area that the fund’s examining is the impact of COVID on the healthcare workforce. “We've known that there's the big challenge of fatigue and burnout, demoralization. There may be a place for us to look at how we might fortify the workforce.”

In terms of grantees, Betancourt had this message: “That experience, having been on the other side, for me, will be very helpful as we think about ways in which we can continue to do better.” While figuring out next steps, he said, the fund will want to hear from grantees and stakeholders. “Grantees play an important role in who we are, the impact we create and how we shape our future.”

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