More than 20 years ago, a history professor then on the faculty at New York University published a remarkable prize-winning book about the Great Depression.
Lizabeth Cohen’s Making a New Deal argued that the searing experiences of the 1930s fundamentally upended the way Americans conceived of the nation’s social safety net.
During the Hoover administration, many of the country’s private social-service agencies — institutions like the Bohemian Charitable Association, the Polish Welfare Association, and the Jewish Home for the Aged in Chicago — went belly-up; at the same time, businesses that for generations had been a caregiving backstop were forced to pare down their employee benefits and siphon off their charitable giving. The needy were forced to look elsewhere for help.
Arguments abound today over whether the New Deal really solved the nation’s troubles. But no one can deny that FDR’s White House tenure was the beginning of a broad transformation in the nation’s sense of how to solve a big problem.
Faith in large bureaucracies reached its zenith in the wake of the New Deal and the war, propelling the nation into what would later be pilloried as an "era of big government." But as is evident by the nation’s plummeting faith in institutions all across American life, the way we take care of one another has once again become outmoded. And it will largely be up to philanthropy to show the way forward.
The pillars we rely on today were not entirely absent in the 19th and early 20th centuries.
But on a host of fronts — National Institutes of Health funding for new treatments that can make a difference, Medicare support for doctor visits, Medicaid dollars for nursing-home care — our modern health-care infrastructure emerged from Washington. Unfortunately, for all of its blessings, that progress has also come at a cost.
In too many cases, government bureaucracies have supplanted the primary role that community once played in guaranteeing care from neighbor to neighbor.
Because a range of services could be provided in a single hospital ward or nursing-home wing, demand for the kindness and dependency that was once commonplace between neighbors and friends diminished. The expectation that your pals from the Rotary Club might help your family if you lost your job, for example, faded when unemployment insurance emerged to provide relief. The common expectation that neighbors would regularly look in on the aging couple down the block has dissipated over time.
Those twin developments — the miracle of modern institutions and the winnowing of neighborly community — have left us today in an uncomfortable spot.
In the absence of an ability to depend on friends and neighbors, we’ve come to expect professionals — doctors, nurses, home health aides, social workers — to fill those roles. And because we now live longer, the demands of those who endure chronic conditions like Alzheimer’s disease have ballooned.
The Great Depression it is not. But in an echo of the sea change that brought about the New Deal, we’ve come yet again to a point at which our incumbent social safety net is no longer properly aligned with our needs. It’s no wonder, then, that the nation’s entitlement system seems ill-equipped to keep up. We’re trying to drink soup with a knife. The nation’s incumbent social safety net was designed to solve an entirely different (and blessedly diminished) set of social and medical challenges.
Just as Americans realized during the Great Depression that there were alternative means to caring for those in need, we don’t now have to depend on the model forged after the 1930s.
It’s not that we need to abandon the progress we’ve made. But we’ve never before been so better equipped to provide the care that would prevent Americans from having to depend on big, centralized institutions. We have scooters and walkers, special beds and custom toilets, new ways to monitor vital signs, and many sophisticated ways of accessing and combining information about individual patients in real time.
It used to be that we institutionalized the old and the frail because, during the industrial age, the most efficient way to deliver services was to centralize them. Today, traditional home-health agencies aren’t the only alternative to institutionalized care; those living with chronic conditions can frequently be afforded the dignity of independence with malleable, tailored, and evolving forms of help. And because a dynamic alternative to institutionalized care would allow many (though certainly not all) frail and elderly Americans to avoid living the final years of their life in a hospital or nursing-home ward, the costs being borne by the nation’s entitlement programs would inevitably lighten as well.
What stands in the way of our capacity to provide a dynamic alternative to institutional care?
It’s not lack of demand: Older Americans are frequently desperate not to lose their independence.
Nor is it a lack of supply: In many American communities, though certainly not all, the individual pieces of what would make up a real alternative to institutionalized care already exist.
Rather, in most American communities there’s a near total absence of the vibrant interconnectedness that might otherwise allow existing care providers — social-service charities, Meals on Wheels, physical therapists — to piece together the kinds of help needed to keep Grandma from being sent to a nursing home.
The question isn’t whether to build more traditional home health care, a service that is frequently more expensive than what might be offered in a nursing home. It’s whether networking resources together could keep some significant portion of America’s elderly and infirm population independent at a much lower cost.
We’ve got all the equipment necessary to provide a new alternative, but we haven’t woven them together into a tangible substitute. And so the challenge is to reverse-engineer the magic that once existed in tightly knit neighborhoods by tying together the nation’s existing providers.
It’s not that we’re ever going to dismantle the entitlement programs that have emerged to become something of a miracle. We need adequate support for the hospitals and nursing homes on which Americans have come to depend.
But think what might happen if we applied all the benefits of social networking to caring for older Americans. If systems were in place to ensure that elderly Americans were eating well, taking the right medications, avoiding the frayed corners of old rugs, bathing regularly, and keeping their finances straight, millions fewer would be institutionalized.
If the patterns of care that existed earlier in American history still prevailed, Washington wouldn’t be in such a financial bind. In sum, we need service providers to fill in the gaps that have been left vacant by the absence of family connections.
And that’s the root problem.
In too many cases, and often through no fault of their own, the bureaucracies — hospitals, insurance companies, government agencies — now positioned at center stage aren’t equipped or inclined to develop a more flexible, individualized alternative to institutional care.
Fortunately, however, the country’s foundations are not so encumbered. They have the wherewithal to begin breaking through the status quo.
There are already good illustrations of how that might work.
Look, for example, at the work being done by my colleagues at the Bill, Hillary, and Chelsea Clinton Foundation.
Beyond steering funds to worthy projects designed to aid the needy — and then managing and expanding what works best — the foundation’s focus is on bringing together people with different skills, strengths, and viewpoints in the hope that they will collaborate in developing new solutions to tough problems. There might once have been a time when those ties would have been forged organically because grant makers, providers, and experts knew each other through the Rotary Clubs, bowling leagues, and neighborly familiarity that is now a vanishing norm.
The convening power that foundations wield may be the most important tool available in the search for a more dynamic, efficient social safety net.
And it’s not being done just at the scale of the Clinton Global Initiative.
Organic efforts to connect local social-service providers are beginning to emerge in communities around the country.
Not long ago, Jonathan Rauch of The Atlantic profiled the efforts of several disaffected veterans of the medical community in the Bay Area to build connections among service providers that would keep elderly Americans at risk of institutionalization at home.
And an entirely new approach being developed outside of Buffalo, called a "Town Square for Aging," aims to bring disparate social-service providers under a single roof. (Full disclosure: My father is among those working to lift the Town Square concept off the ground.)
In each case, the goal is simple: to build relationships among existing care providers who, when working in collaboration, can begin to spell some of the burden being placed on families under the incumbent social safety net.
When The New Yorker’s George Packer wrote The Unwinding last year, he unveiled something many Americans know and feel to be true. The institutions that have served as the underpinning of care in America since the New Deal are no longer up to the task.
The good news is that despite all the challenges — income inequality maybe most worrisome of all — we have the resources and tools to take care of ourselves like never before. If America’s underlying social architecture has changed, the means by which we lift up those in need will have to adjust. That, in the end, needs to be a central mission of American civil society.