The Death & Life of Great American Healthcare
What Jane Jacobs and Robert Moses can teach us about healthcare today
The text below is a lightly edited version of “Death and Life of American Health Care,” published in January 2018 by InsideSources and by the Mercatus Center.
EXPERTS VERSUS PEOPLE
For a century, the great philosophical divide in America has revolved around the locus of decision-making. Are details of our lives to be determined by ourselves or by centralized experts? Should governments prohibit individual risk-taking or should we be free to take chances? Which is better: a tidy world planned from on high, or a messy world improvised at street level?
My 2014 monograph, Fortress and Frontier in American Health Care, argued that the centralized, risk-minimizing, tidy ideal (“the Fortress”) dominates thinking in healthcare, while the individualistic, risk-taking, messy view (“the Frontier”) has driven the explosion of innovation in information technology.
Back in 2018, my wife and I watched a dramatic rendition of Fortress versus Frontier: “Citizen Jane: Battle for the City” — a 2017 documentary about the titanic struggle between New York’s urban planner Robert Moses and journalist Jane Jacobs. For me, the film has lessons about contemporary healthcare.
CITIZEN JANE VS. THE POWER BROKER
Moses was New York City’s master builder throughout the mid-20th century. Immensely powerful, he bulldozed neighborhoods to make way for vast expressways, housing projects and parks. Jacobs was a journalist (disparaged as a meddlesome “housewife”) who gathered a movement to halt Moses’s overreach. Today, many (me included) tend to remember Jacobs as a visionary and Moses as a despot who scarred a great city. But both clearly sought the betterment of New Yorkers.
Moses preferred towering, neatly geometric housing projects, severed from their surroundings by impassable expressways. He demolished communities and exiled residents, saying, “I raise my stein to the builder who can remove ghettos without removing people as I hail the chef who can make omelets without breaking eggs.”
In the late 1950s, Moses decided to bisect a much-loved park with a high-speed expressway. Jacobs, whose children played in the park, begged to differ. She wrote and spoke and organized people — mostly women, initially — to scuttle the plan. It worked.
Jacobs summarized her revolutionary view of cities in one of the greatest books every written on urban design: The Death and Life of Great American Cities, a broadside against urban planners’ obsession with orderly, sanitized, rectilinear cities. For Jacobs, messy serendipity was what made cities lively, safe and productive. Messiness meant new buildings next to old, commercial next to residential, and activity at all hours of the day and night — anathema to planners.
Above all, hers was a vision of decentralization, saying:
“Cities have the capability of providing something for everybody, only because, and only when, they are created by everybody.”
She concluded that safety didn’t come so much from professional police officers as it did from the thousands of eyes on the streets: pedestrians, drivers, merchants, customers, diners — eyes that were absent in Moses’s barren, windswept housing projects.
Jacobs recalled a conversation with a Boston urban planner who said the city’s heavily Italian North End was a mess and needed massive urban renewal. Jacobs said she found the neighborhood vibrant and chaotic and exciting. The planner said he, too, liked the North End and often went there for recreation, but reiterated that it was a mess and needed to be rebuilt. The streets were crooked, the sidewalks narrow and clogged with pedestrians walking and children playing.
Later, Jacobs found that North End had extraordinarily low crime rates. Though a relatively poor neighborhood, people wandered at all hours with little fear of crime. A local community leader told her, “I have never heard of a single case of rape, mugging, molestation of a child, or other street crime of that sort in the district.” In contrast, Boston neighborhoods that conformed to planners’ ideals were often cesspools of crime and disease.
BULLDOZING HEALTHCARE
What does all of this have to do with healthcare? While listening to the documentary, I thought, “In healthcare debates, practically everyone is Moses, and hardly anyone is Jacobs.” Liberals calling for single-payer want the federal government to be Moses. Conservatives supporting certificate-of-need laws or limitations on nurse practitioners prefer that states (or perhaps professional medical societies) be Moses. (As I’ve often said, “Liberals believe the federal government’s role in healthcare is to interfere with markets and frustrate consumers. Conservatives believe that the task of interfering with markets and frustrating consumers is best left to state governments.”)
Few in the healthcare debate call for the messy, decentralized, individualistic decision-making that Jane Jacobs wanted for cities. And this absence, I believe, is the major reason that healthcare innovation has grown sluggish and healthcare debates are so vitriolic and unproductive.
[NOTE: In 1978, my wife, Alanna, co-authored a landmark book—SoHo—on the subject of New York’s then-nascent arts district. Without Jane Jacobs’s protests, Robert Moses would have bulldozed the neighborhood before Alanna had a chance to write her book. She and I discussed her book and a good deal more on Jacobs and Moses in our Bastiat’s Window essay, “SoHo + 45: Avant-Garde's Hot Center Revisited.”]
MRS. MAISEL MEETS JANE JACOBS
In one episode of Amazon Prime’s hit series, The Marvelous Mrs. Maisel, the eponymous Midge Maisel (Rachel Brosnahan) encounters Jane Jacobs (Alison Smith) at a 1958 rally protesting Robert Moses’s plans to run an expressway through the middle of Lower Manhattan’s leafy green Washington Square Park. As a Jane Jacobs enthusiast, I was delighted with how well the show’s writers (led by Amy Sherman-Palladino) captured the Jacobs-Moses battle. This was no surprise, as the scripts were meticulously peppered with obscure cultural references concerning late-50s, early-60s New York City—especially references to the neighborhood around Columbia University, where I studied, Alanna worked, and we lived. (The writers did occasionally take liberties with facts and chronology. Scenes sometimes featured songs that were not yet written during the show’s timeframe. For persnickety food-lovers, a particularly ghastly anachronism was Midge, circa 1960, referring to General Tso’s Chicken which did not exist prior to the 1970s.)
It’s more my opinion than any sort of objective observation, but it seems that attempts to manage human behavior, whether through incentives or laws, frequently end up making things worse for almost everyone involved. Lots of people have difficulty understanding the difference between “complicated” and “complex,” as well as a stubborn refusal to take into account human nature.
I came across Jane Jacobs about the same time as the ACA was being implemented and the thousands of pages of regulation were being written (bulldozing what little free market there was left in the health insurance business. I also came across THE CLUETRAIN MANIFESTO and the concept of technology allowing consumers to flip the table on the consumer-to-vendor relation model: turn CRM into VRM.
10 years after, the most disappointing thing about the ACA is what it did to health records and any possibility of consumers managing their vendors rather than being captured. Who would have thought that throwing billions of tax payer $ at something would create perverse incentives and lead to the capture of consumer data?
Imagine if something like Microsoft Health vault had taken hold and innovators built easy-to-use tools to move data in and out of the vault. Consumers could connect to digital apps. Consumers could share portions of their health history with brick and mortar providers. Consumers could have aggregated their own data with other consumers and solicited bids to provide them with catastrophic coverage or micro-coverage.
Instead, we have siloed data which is owned by a few select EHR vendors to use as they see fit (like selling it back to the providers who captured it in the first place).