Editor’s Note: Philanthropy expert Amy Schiller will periodically explore big donations and where they fall on the good philanthropy/bad philanthropy continuum. Look for more from her on that subject in the months to come.
Michael Bloomberg has succeeded at the highest levels of business, philanthropy, and politics, both because of — and in spite of — a moderate pragmatism that takes the euphoric edge off of even his biggest accomplishments. His 2020 presidential run even made the case for a “boring president” who could offer exhausted Americans a respite of dry, competent technocracy.
In other words, only Bloomberg could make a billion-dollar donation that will transform thousands of lives seem, well, boring.
To be clear, Bloomberg’s announcement last week of a $1 billion gift to Johns Hopkins University is a good thing over all. It will make medical school free for most students and expand financial aid for those pursuing nursing and public-health degrees. This will ensure that health care students flourish and find fulfillment in their careers, not just earn the biggest paycheck.
Bloomberg’s statement emphasized that the gift would help more students “pursue the fields that most inspire them, rather than ones that will best enable them to repay graduate school loans.” All education philanthropy should take this tack.
The inclusion of nursing and public-health students as beneficiaries is also significant. Physicians get the most prestige and visibility, but they rely on the labor of many other health care workers. It’s equally important, if not more so, to allow the best and brightest to pursue nursing and public health debt-free.
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The comparison between Bloomberg’s gift and Ruth Gottesman’s $1 billion donation in February to the Albert Einstein College of Medicine is unavoidable. But there are important differences. Most notably, Gottesman’s gift made Einstein tuition-free for all students, not just those who qualify as sufficiently low-income, while Bloomberg’s donation applies only to families earning less than $300,000. It also covers living expenses for students whose families earn less than $175,000.
Lack of Oomph
This approach is in line with the Bloomberg hallmark of targeted impact, such as his previous proposal to slash Social Security so it served only the “neediest recipients.” Characteristically, he’s also uninterested in dismantling the marketplace structure of health care, believing that paying for medical services makes better economic sense. This takes away the gift’s transformative oomph by failing to focus on the bigger picture.
Some will argue that means-testing the beneficiaries guarantees the money goes where it’s needed most, but it also ensures education remains a commodity. Students are still consumers paying for a service. As Howard Wolfson, Bloomberg Philanthropies’ education program lead, put it, “Families who have the ability to pay should pay.”
The gift, as a result, does not radically change the nature of education by making it accessible to everyone. Means-testing also creates unnecessary bureaucracy: What about students whose families won’t pay for graduate school or who face high care-giving costs? What happens if a family’s income decreases dramatically one year? The financial cutoff creates confusion and barriers to entry, while universally free goods, such as libraries and parks, create solidarity and community.
This brings us to the ultimate question about this gift: What problems in American health care is it trying to solve? It will certainly make Hopkins more competitive, including many more applications and a lower acceptance rate. It should also make the school more diverse. If the goal of the means-tested subsidies is to increase the number of students of color or those from low-income families, then the school must invest in outreach and recruitment programs in those communities.
But if the goal is to expand overall health care access, reducing student loans is just one piece of the puzzle. In an interview with the Conversation, Amir Pasic, the dean of the Indiana University Lilly School of Philanthropy, noted that “just waiving tuition — which costs about $65,000 annually for four years — and doing business as usual won’t make a difference.” Instead, Pasic said, medical schools need to create a culture that “encourages and expects their alumni” to work as primary-care doctors or in low-income communities.
Missed Potential
Making medical school tuition-free also does not solve the economic challenges of pursuing a career in primary care or working in an underserved area. Corporations are consolidating primary-care practices, and private-equity acquisitions of medical practices are rising 20 percent a year, which makes health care increasingly oriented to efficiency and profit. Meanwhile, people endure long waiting lists and rushed provider visits. Doctors are limited by the pressures of profitability, the amount of staff time and expertise to negotiate with for-profit insurers, and patients’ reluctance to seek health care when deductibles are high.
Bloomberg’s gift is a good move for a philanthropist, but he wears many hats and has more levers of influence. If, as his statement about the gift indicates, he’s concerned about the shortage of medical professionals and a decline in life expectancy, then surely a man with his knowledge, political connections, and savvy can devise a multipronged strategy that reduces the for-profit mandates in health care. That could include an endowed fund providing grants or low-interest loans to practices that need help to stay afloat or staff up, or funding to pilot a health care version of the Civilian Conservation Corps.
Ultimately, Bloomberg’s clockwork pragmatism and moderation may have limited his thinking. His gift is a net positive, but without a bigger strategy, its effect on the problems he’s identified in American health care will be limited.