The basic function of money is to bring needs and resources together. But the conventional money system is failing miserably in this regard. Vast human resources sit idle, while vast needs go unmet - often in the same neighborhoods, even the same block.
This has large implications for the debate over social services, health care included. Perhaps the question isn't just the government versus the market, spending more versus spending less. Perhaps we have to start asking questions about the kind of money we use. Lawmakers in Washington are busy trying to construct legislative contraptions to make the market - i.e. greed - result in better care. But just maybe, a new kind of money could give rise to a new kind of market, with care built in.
That probably sounds pie-in-the-sky. It would seem less so if you had been at an apartment house in Brooklyn on a crisp sunny day last fall. Vincent Rescigno, dapper and spry, has come to take Jean Miccio shopping, which he does once a week. He's a retired electrical worker, with spare time and a desire to help. She'd had a bad fall a few months earlier while rushing to catch a bus, and because she lives alone, getting around is a major challenge. She could easily become yet another burden on the nation's struggling health care system.
But Vincent and Jean belong to a nonprofit HMO (health maintenance organization) for seniors called Elderplan, which has a unique approach to health and care. At this HMO, members help take care of one another. They cook and provide companionship for the house-bound and infirm. They provide rides to doctors and help with shopping. Some have been trained to counsel the bereaved. There's even a home-repair service, run by an Elderplan member who is a retired contractor.
Passive recipients of medical services become active providers of health and care. People the system defines as burdens, become producers and contributors, and an insurance company turns into a community. The system works on a new kind of currency, called service credits or Time Dollars, which are spreading across the US. Service credits are a way to bring needs and resources back together - as the example of Jean and Vincent shows - and build community in the process.
The Elderplan approach addresses one of the most neglected needs among older Americans today - the "need to be needed," as Edgar Cahn of the Time Dollar Network in Washington, DC, puts it (see page 24). The market calls older people "consumers"; the government calls them "service recipients." Elderplan calls them people with a lifetime of experience and a desire to share it.
Time Dollars help to activate that experience. This in turn encourages health in the true sense of the word; health becomes an activity, something people do, rather than just a commodity bought from experts for money. Studies have shown repeatedly that community is health-maintaining. People involved in helping others are less prone to disease than those who aren't (something advocates of "market-based" policies, such as individual medical accounts, generally overlook). Rescigno notes proudly that in the last five years he's had nothing worse than a cold. "The only reason I'm as healthy as I am," he says, "is that I'm so busy helping other people."
Creating health through community In the 1980s, medical policy experts were wrestling with a stubborn fact: the nation's burgeoning medical costs weren't just a matter of doctors and drugs; social breakdown was playing a big part too. Families break up. Neighborhoods change. Children move away. The mobility that free marketeers worship was eroding the informal matrix upon which the medical care system - and society itself - depends. Much disease is borne of loneliness and isolation. Nursing homes are full of people who could easily be at home if they only had some help with daily functions.
The answer of the policy experts was a new kind of social HMO, the SHMO, which would cover certain social services along with conventional medical care. Ensure that a widower gets proper meals when he's released from the hospital, for example, and he might not return so quickly. Invest in prevention and save on cure. Congress authorized a number of experiments with this model, and Elderplan was one.
It should have been an ideal setting. Brooklyn is still a place of neighborhoods and strong social ties. Yet even here, the need for services soon proved far greater than Elderplan could begin to meet with the Medicare allotment alone. So it started thinking about the untapped resources already at hand. It wanted more than the usual volunteer program; it wanted a sense of real community, in which members help one another in a spirit of give and take.
The service credit concept offered a way to accomplish this. (The Robert Wood Johnson Foundation helped promote the concept with seed grants.) Service credits work like a blood bank, except instead of blood, members contribute time. The content of a conventional dollar is a vague promise on the part of the federal government, which is already a trillion dollars in debt. The content of a service credit, by contrast, is a neighbor's commitment to help in times of need.
When Vincent gives Jean a ride to the store, for example, he gets a credit in a computer bank that he can draw on when he needs help himself. At first it might sound crass - getting credit for helping others, which we ought to do for free. But in practice the system replicates the collective memory bank of small towns and stable inner-city neighborhoods, in which good deeds were remembered and returned in due time.
The encounter at the Brooklyn apartment is an example. This simple act of neighborliness was actually part of a growing web of reciprocal help and care. Jean used to provide rides and help with shopping for another Elderplan member. Now that she's laid up, Vincent helps her. She in turn makes "telephone reassurance" calls to an older member who is more isolated than herself. "It's helpin' one another out, like a family," said Herbie Fine, an Elderplan stalwart until he died a few years ago.
There were skeptics in the beginning. The frequent response was, "You really think people are going to contribute volunteer time to an insurance company?" recalls Mashi Blech, a senior manager at Elderplan.
Today there are some 125 active volunteers, who put in between 800 and 1,000 hours per month. (Many additional hours go unreported.) Since 1987, the program has provided at least a half-million dollars worth of care (and probably many times that in uncredited services) that the HMO couldn't have afforded otherwise. To the extent the extra care at home helps keep members out of nursing homes, the savings are much more. A study of one Social HMO in California found that members resorted to nursing homes at about half the rate of Medicaid recipients nationwide - and that was without the kind of volunteer program that Elderplan has mustered.
Such statistics have obvious appeal to legislators and medical care administrators. With nursing home costs running $35,000 to $40,000 a year or more, the potential savings are not small.
Friends helping friends Far more important, however, is the increased quality of care that members can provide one another. There are, for example, the subtle sensitivities of aging that get lost in the debates over spending more versus spending less. Many older people don't like to deal with professional social workers.
"They don't want to talk to some young girl in her 30s about the death of their husband," says Dorothy Gochal, an Elderplan peer counselor who thought she had nothing to offer until Elderplan came along.
Fellow members, by contrast, connect to one another like friends. They understand the problems of getting older because they are going through those same problems themselves.
"When people hear the word Ã”counselor' they think Ã”professional'," Gochal says. "But when they find out that we are ordinary people, the same age, and Brooklynites - oh my, you really have an in."
Moreover, fellow members sometimes pick up cues that professionals might miss. Vincent is helping an older man who was severely depressed and talking about suicide. One day he went with the man to an auto repair shop and noticed that the man's mood improved greatly when he got out of his house. After that, instead of meeting at the house amidst the ghosts of the past, they met at a coffee shop. The man no longer talks of suicide, and his outlook has been steadily improving.
This kind of instinctive response to another's need goes directly against the dominant trend in medicine today, which is to declare people "depressed" and treat them with drugs.
"Managed care is coming to the view that drugs may be the cheapest form of care," William Steere Jr. of Pfizer Inc., told Business Week recently. Cheap, no doubt, but also penny wise and pound foolish, not to mention chilling in its larger implications. Over-drugging has become a pervasive problem; some 32,000 hip fractures and 16,000 car accidents a year stem from the use of prescription drugs to treat the elderly.
The Elderplan model offers a way to reverse that dehumanizing process and to tap human resources that the current system ignores. Avis Rhodes, for example, is a serene and sunny woman who speaks with the soft inflections of the Caribbean. She used to be a psychiatric nurse, and through Elderplan she is able to put her skills to use. The day I spent with her, she took a long bus ride out to Coney Island to work with a Jewish woman in a nursing home. The woman had been a terror to the staff, but after Rhodes started visiting she became more cooperative and friendly. "They open up and tell you things they would not tell their families," she says.
Then there's Ray Hughes, a retired merchant seaman with the warm caring manner of a parish priest. Hughes went through the peer counselor training program and now leads a support group for members with problems at home. The group meets in a church function room, complete with supermarket pastries and instant coffee.
The day I attended, they talked about problems with spouses who were failing or abusive. Caring for a spouse with Alzheimer's is a grueling, thankless task. "Alzheimer's involves two patients, the one who has it and the one who takes care," Hughes says. "The caregiver is the one in crisis."
That was apparent from the people around the table. Some felt angry at their spouses, and guilty for feeling angry. Some were simply overwhelmed. The sense of comfort and release was palpable; here were others who understood. Hughes kept the meeting moving with a light but firm hand, always guiding the discussion towards positive steps.
"It's almost as though I came to Elderplan so I could learn how to cope with my own problems - which there was no way to predict," Hughes says. When one of his sons died, there was no shortage of fellow members to offer comfort and support.
The service credits themselves don't matter much to members like Hughes. But for others they serve as a kind of scorecard, an affirmation of a job well done. They also remove any stigma of charity; members feel they earn the help they receive, or will pay it back if they possibly can.
The credit system also provides a flexible growth dynamic that bureaucratized programs lack. The system evolves spontaneously like the market, but in response to human need rather than monetary "demand."
A few years ago, for example, an Elderplan member broke the towel bar he used to get in and out of the bathtub. The man was in his 90s and beside himself with worry. But then another member, a retired contractor, fixed the bar. This incident evolved into a home-repair service, which has now become a home-inspection program to catch unsafe conditions before they result in accidents.
There are physical fitness classes and arthritis counseling for the homebound, conducted by volunteers through conference calls - all connected to the service credit system.
Money that taps community capacity The Elderplan approach raises basic questions about the role of money in economic and social change. Is it possible that the nation's problems are grounded not just in what we spend money on, but in what kind of money we use?
Money isn't just a means to carry out transactions, as economists say. The kind of money we use determines, in large measure, the kinds of transactions that occur, and the kind of economy that results. Conventional money is a means of transaction between strangers, and so encourages an economy in which people deal with one another in that way - an economy of Wal-Marts instead of Main Streets, overseas sweat shops instead of production closer to home. Conventional money knows no loyalty to locality or even country, so it tends towards a global economy in which traditional social bonds give way to a rootless quest for the highest monetary return.
Service credits are a way to reverse that process. They have a social content and so offer a concrete way to rebuild the nonmarket economy of family and community that the market tends to erode. They provide a counterweight to the centrifugal forces of the money-driven global market.
As an alternative currency, service credits also point toward a new model for social services. John McKnight of Northwestern University has observed that the prevailing social service system mimics the corporate marketplace, in that it is based upon a "need for need." Too often, government programs stem from the need of professionals to keep busy rather than the need of the poor to be well. The result is a belief that "the malady is in the person and the cure is achieved by professional intrusion into that person."
Service credits, by contrast, start from the premise that people and neighborhoods have capacities as well as needs. Participants become "co-producers" - in Edgar Cahn's term - of the improvements the programs are trying to achieve.
The approach does not deny the need for services; rather it turns recipients into active providers of services. This approach is spreading rapidly around the country. In St. Louis, a social service organization called Grace Hill has used service credits to build a bustling local economy in which some 3,000 participants will earn over 50,000 credits this year, for everything from child care to car repair. Participants also can use service credits to buy household items at two simple stores, stocked through donations. The work will qualify under the new welfare bill.
In the South Bronx, an employee-owned home care provider called Cooperative Home Care Associates, is developing a service credit program to meet the needs of both individual workers and the organization as a whole. The program will provide daycare for the children of the owner-employees, most of whom are former welfare recipients. It will also encourage time-barter among the staff. "Time Dollars represent a way to create a sense of connection among people as we grow," says Rick Surpin, president of CHCA.
For Elderplan, perhaps the most important part of the co-production model is the way it redefines health from something bought for money to something people do. Mashi Blech, a senior manager at Elderplan, tells the story of a member who spent his days alone in his apartment. He was a double amputee and partly paralyzed by a stroke, and social workers determined that he needed home visitors. But when Blech called to match him with a volunteer, she found a man who was "full of life and energy and enthusiasm." Instead of sending him a volunteer, she asked him to be one.
So the man, a former real estate salesman, became the coordinator for a team of volunteers. Blech arranged his transportation to the Elderplan office, where he helped with paperwork and trained to become a telephone counselor. The man was certified for a Medicare-paid nursing home, which would have cost the system some $35,000 a year. Instead, he spent his final days lighting people up with his humor and zest.
Jonathan Rowe is coauthor, with Edgar Cahn, of Time Dollars. He is program director at Redefining Progressin San Francisco, an organization innovating new ways to create and measure economic well-being. Portions of this article appeared in Jonathan Rowe's earlier article in US News and World Report. Edgar Cahn is the inventor of Time Dollars and the founder of the Time Dollar Institute(see resource guide). He is a professor of law at the DC School of Law and was one of the pioneers of the nation's legal services and anti-poverty programs.