More than four years after it was promised, a foundation created by state lawmakers to help New Yorkers get health care is, at last, up and running — and with much more money at its disposal than expected.

The Legislature and Gov. George E. Pataki created the New York State Health Foundation in early 2002, but the law was challenged in court, freezing the plan for almost four years. By the time the foundation could begin operating, the assets the state had given it had grown from a value estimated at $50 million to more than $250 million.

There are charitable foundations with billions of dollars, but they have much wider missions. The New York Health Foundation has enough grant money to give away to become important within its narrow mandate, limited to health care and to New York.

Its board hired James R. Knickman in April as its president and chief executive, giving it a leader with deep experience in health care, the charitable world and New York. The foundation plans to publish its first request for grant proposals this month.

Yet the group has barely begun to define its identity and purpose. Mr. Knickman has not yet hired a staff, and the request for proposals is expected to be very broadly worded.

Talk to Mr. Knickman, or to the voting board members appointed by the governor and legislative leaders, and what emerges is less a specific set of ideas than excitement about the range of possibilities. One issue that arises repeatedly is the epidemic of obesity and diabetes.

"We are very interested in finding three or four areas, to focus on these and really have an impact," Mr. Knickman said.

The foundation has a broadly worded, three-part mandate from the state: to expand health insurance coverage for people who cannot afford it, improve access to care for people who have trouble finding it, and educate people about health issues and help them address those problems.


Tackling such enormous problems head-on — to insure the uninsured, or open new clinics — could cost billions of dollars, clearly beyond the foundation's capacity. And its leaders say they are not particularly interested in being a "think tank," writing and commissioning papers on various issues; many groups do that already.

What they talk of instead is supporting small-scale, neighborhood-level efforts by community groups, clinics or schools, finding what works, and trying to show how it can be replicated elsewhere. "We're thinking in terms of demonstration projects," said Deborah Konopko, the foundation chairwoman.

Mr. Knickman said, "We want to find innovative people trying innovative things and support them, and maybe join forces with other organizations."

He cited some examples to emulate, like the Harlem Children's Zone, a group that works on a range of problems, from asthma to drug abuse, in central Harlem. He also spoke enthusiastically of a project in Upper Manhattan by a national organization, Community Voices, working with neighborhood groups to connect low-income, uninsured people with clinics and doctors.

"I'd like to take something like that and do it in 10 communities," he said. "I could see helping community health centers with investment in technology and better management, to make them more efficient."

The board members, and others in the health care field, see the hiring of Mr. Knickman as a coup. Most recently, he has been a vice president of the Robert Wood Johnson Foundation overseeing health care grants, and chairman of the Robert Wood Johnson University Hospital in New Jersey. Earlier, he was a longtime professor of health policy at New York University's graduate school of public service, and he worked for a time on health policy in Mayor Edward I. Koch's administration.

Despite their enthusiasm, some of the foundation's supporters cannot help but view it wistfully, believing that it should have been wealthier.

In January 2002, the Legislature and governor passed a law allowing Empire Blue Cross Blue Shield to convert from a nonprofit corporation to a profitmaking one, under a new parent company, WellChoice. As a condition of the deal, the state claimed ownership of some of the newly issued WellChoice stock, as compensation for Empire's decades of being tax-exempt.

Some states that had allowed such conversions, including California, had used most of the revenue, billions of dollars in some cases, to create foundations promoting health care for the poor.

But New York lawmakers, over the objections of a few of their colleagues, seized on the conversion as a source of money to pay for a new contract with the powerful hospital workers' union. They set aside just 5 percent of the stock for a foundation.

No one knew for certain what price WellChoice would fetch on the open market, but at the time the law passed — in the midst of a recession — state and company officials estimated the value of all the outstanding stock at $1 billion, and the foundation's portion at $50 million. When the state sold some of the stock nine months later, it found that the market price was about twice that high.

Consumer advocates who believed that more of the stock should go toward public health challenged the conversion law in court, with a string of lawsuits and appeals that prevented sale of most of the stock for long stretches of time. Paradoxically, those delays turned out very well for the state and the foundation. The economy improved, health insurance industry stocks soared, and WellChoice was taken over by WellPoint, a national insurer, pushing the stock still higher.

Today, the foundation's assets are worth about $250 million. In all, the windfall to the state has been about $5 billion, much of it still in the form of stock. It is not clear how that money will be spent.