Neighborhoods as Patients

Speaker A: Before we start, I want to invite you to Rosetta Fest 2026 in Nashville. This is where employers, unions, and clinicians who are cutting healthcare costs 20 to 50% while improving care and outcomes share exactly how they did it. Operators learning from operators with patients at the table. Learn more and register@RosettaFest.org now let's get into today's conversation.

Speaker B: Many things have gotten better in America over 50, 60 years, but for sure, the thing that has gone down the worst is the nature of our relationships. Locally, there's no incentive for anyone to make neighborhoods better.

Speaker A: I found oftentimes the mindset shift is the biggest hurdle. Is there a particular mindset shift? You know, maybe it's just echoing what you've said.

Speaker B: When you govern by neighborhood versus governed by silo, your mindset is different. Your allocation of money is different. You actually care about place, results. The neighborhood is the patient. Life is more joyful, more happy when you're in these great neighborhoods.

Speaker A: Welcome to Relocalizing Health. I'm Dave Chase. Something's happening in neighborhoods around the world right now, and most of it's happening without anybody, you know, formal planning. But there is a movement and some of that implicates healthcare for sure. For example, uh, nurses in Netherlands who are organized into small self managing teams and have rebuilt home care around the neighborhood instead of in a clinic. In Baltimore, there's community health workers and nurses that started going door to door in the city's own apartment buildings. They borrowed an idea from Costa Rica's primary care model. In the UK, the NHS is building integrated neighborhood teams that pull in the GPs, the social workers, community groups into the same room for that population. And we'll talk some about Singapore in particular. They rebuilt their healthcare system around really resident led neighborhood nodes. And you know, in a previous episode we had April Kyle with the, uh, South Central Foundation. And what the Alaska native people did, their community, which once had almost no voice in their healthcare, has built a system that many consider the best in the world. You know, different continents, funding systems, politics. But they can compare notes and learn from each other. And the common thread that we've seen is they land on the basically the same answer. You know, stop treating patients as waiting for services, start treating them as neighbors who produce their own health. And you know, if you could put the results of these efforts into a pill bottle, it would be like the blockbuster drug of the century. My guest today spent his career studying why some neighborhoods and nations hold together, others fracture long before turning his lens to healthcare. Seth Kaplan is the Author of a book I highly recommend for fragile neighborhoods, and most recently had an article titled Community Centered Healthcare that we're gonna talk about some. And what I found is I came at the same problem, but from more the healthcare perspective. And so we're gonna work through, you know, what it takes to build this type of thing in an American community, since it's self evident that an entirely new model needs to arise out of the failings of our current system. Seth, welcome to Relocalizing Health.

Speaker B: Great pleasure to be here. I think this is a important topic for everyone, but particularly people in healthcare.

Speaker A: Yeah, so much so. And really enjoyed all the stories in the book. And you know, when I read it, I did see these parallels. And I think those who are building the new healthcare economy and new ecosystem can learn so much from your research. And you know, your career was really focused in on kind of state fragility. Fragile states, I think, as you call them, but also more recently now, neighborhood cohesion, not about healthcare. What pulled you into writing about healthcare and hospitals and insurance and some of those things?

Speaker B: Well, I'm gonna give you a two part answer because first I got pulled into neighborhoods and later I got pulled into sectors like healthcare. So the beginning of this journey is that I'm known in Washington a little bit as Mr. Fragile States because I worked on. In fact, I continue. I just had a call today on Nigeria. I have a big project in Nigeria, uh, and I worked on Fragile States for much of the last 20 years. And people know me with this topic. And then about 10 years or so ago, I would be going around and meeting people. And it's always my pattern that I just go around and meet a lot of people one on one, hear what they have to say, you know, network. Some of it's professional, some of it's just nice way to meet people. And people started asking me, is the US becoming a fragile state? They were very anxious. We're talking 2015, 2016. You have an idea of what's happening with the politics. But they were looking beyond the politics, partly in jest, because I would just come back from Sri Lanka or Somalia, uh, and the United States is nothing like these countries. But it did reflect anxiety. And so I started on a journey like I would any country. I would work on a journey into America, read a lot, visit a lot of places, talk to a lot of people. And basically in general, when I think about the health of countries, I always start with the health of relationships. They seem so far apart and yet something to do with social cohesion the nature of institutions affects so much about us, and then downstream it affects politics and economics. And I knew that internationally. So chapter one here is, I was spending years, this is 2016 to roughly 2020, with a social capital group in Washington, a lot of prominent people from think tanks, people like David Brooks, Bill Galston, Yuval Levin, and then eventually people nationally, because we did stuff virtually. And I was focused on what's the key issue with relationships. And I landed not with the headline, because we are always talking polarization, mistrust, what's wrong with our country in this big, big conversation. And if you ask me what is wrong, wrong and what is the real source of this, it actually those things are downstream because the biggest change we've seen is in the strength of our local communities. Many things have gotten better in America over 50, 60 years. But for sure, the thing that has gone down the worst, and that is responsible for many problems, is the nature of our relationships locally. And so that's chapter one. I wrote the book, I published the book three years ago, and then I went around and talked about it. I went to about 20 cities to talk about my book. I continue to continue to talk about it. And when I reflected, how do I follow up on that and what did I learn? I think the thing that came struck me the most from those several years around, finishing the book, publishing the book, talking about the book, visiting people, was what is going on on a, uh. And the larger nature of our sectors. Health care, finance, governance, social services and so forth. Even things like housing, economic development. I look at all of these and I continue to face what are we doing in these sectors that make it so hard to create flourishing neighborhoods. And so that was the big tension. I was trying to make neighborhoods better, and yet I was seeing that there's larger forces working against that. So that is when I pivoted. And that is why I'm basically working towards my next book. And what you saw was, I guess, a part of, part of what will be a chapter. And healthcare for me, without a doubt, is the sector with the greatest incentive to make neighborhoods flourish because it would directly affect results and cost. And that is why I wrote that article and did the research.

Speaker A: Yeah, no, and it certainly doesn't help that healthcare has become this pac man that's eaten away at, uh, just about every other budget. If you look at state, uh, budgets, for example, it's very direct, you know, and in your book, and certainly people who are familiar with social determinants know that the, you know, medical care, healthcare, you Know, if you take it, the high level is just one of five significant drivers, um, yet it consumes, you know, about 90% of the direct health related dollars. And you know, in my book that just came out last month, I named two structural flaws in the American healthcare system. One very directly related to that, which was we separate funding between healthcare and social care. And then we also get governance. In my opinion, we get governance at the wrong scale. When you look at places that work well, it's either too big, you know, it's far too. It's not accountable at sort of the state or federal level, or too small to really coordinate across the community. Like we're expecting a single primary care doc to solve all of the community issues, which is really not realistic. Um, you know, your piece is very much focused in on that first item. Have you seen a, ah, ripple effect of governance and kind of the scale of governance show up in terms of neighborhoods either impairing or helping efforts? Has that been a factor at all?

Speaker B: When you say governance, Dave, do you mean in the healthcare sector or do you mean in terms of government?

Speaker A: Yeah, like certainly government or entities that really govern. You know, it could be a neighborhood association, but you know, probably most of the time we think about like who owns the responsibility and the dollars.

Speaker B: Yeah. So clearly when it comes to governance, I mean, I have a whole nother chapter and I, I published on my substack a couple weeks ago about Atlanta. For the most part, if you're in a city, for example, or here I'm in a county, Montgomery County, Maryland, over a million people. And there's the government is the county, there's nothing between me and the county. And when you're in a situation in which you have government over a large geography and a large population, everything works in silos. There's no place based strategy. And what my argument would be is we live in places, we live in neighborhoods. There's no incentive for anyone to make neighborhoods better. If you live in a strong neighborhood, there's a lot of social capital, there's a lot of local institutions. People come together, they rally to make their places better, and that's great. But if you live in a neighborhood that is doing poorly, or you live in a neighborhood that's sort of just in the middle, and people don't really have a sense of togetherness or loyalty or there's not local institutions, what you end up happening is that no one takes ownership. No one has a stewardship mindset. If there's a problem, people get up and leave and government Is completely not. Same thing with health care. None of them are structured to take the neighborhood as the unit of change, as the key determining factor for how every else. So when the housing, housing department works, they think of housing, they think of nothing else. When the health, whatever health or healthcare does, it only thinks about individual patients. And you could just go on and on. Transport might work, about moving people, but they don't really care. If the way they design streets or design public transportation, how does that affect these units? I mean, honestly, there's very few places that actually would think this way. There was a survey done recently of a hundred top American hundred cities, and I believe it said that only three had neighborhoods as a priority. And so what Atlanta is doing, which is, which I wrote about and write about more extensively in, uh, my next book, is that they literally are trying to change government to basically measure success and allocate money around neighborhood success. And they have their own metrics. They are changing institutions. And that's because Atlanta has been a successful city. But only roughly 60% of Atlanta succeeds. 40% of Atlanta doesn't succeed. And you have declining property prices, you have stagnant or declining population, and you have anyone who living there, less opportunity, worse health, and so on and so forth. And that's even though lots of money has been spent on these places, but never on making them better. So that's why I do believe it's so true. When you govern by neighborhood versus governed by silo, your mindset is different, your allocation of money is different. You actually care about place results. And that's what we've lacked totally in every sector, especially government. Yeah.

Speaker A: Ah, yeah, definitely. And you know, one of the stories you share in your article is, is from Singapore and there was this four stage arc Yushin Health that really reads like kind of a playbook for making neighborhoods the core infrastructure health. And I want to walk through each stage quickly. I'll, I'll tee up, you know, kind of the stage and then I'd uh, love for you to share what it looks like in Singapore and what you see and when you look for the same pattern or blockers in the. So, you know, the first stage was moves residents engagement out of the hospital into neighborhood community nodes where everyday activities, meal, exercise, socializing and they have this concept of, you know, share a pot bone soup gatherings becoming a routine place where people connect. Um, what did this first stage look like on the ground in that area in Singapore? And when you look at similar efforts, you know, in the US or perhaps abroad, what are some of the key design choices that most determine whether it takes hold or not.

Speaker B: Okay, so I think we need to think about this on two levels. First, the first level is why the organization made this an emphasis. And I think the biggest contrast is why they made it an emphasis in the US I've looked really far and wide, and I do have an example that's not in that article, which I could talk about. Uh, they did something quite different, but they still had a neighborhood centered focus, which was, but it was so hard for me to find. In fact, when I wrote the article, I chose two overseas examples because I had failed to find an example in the US And I looked for it later. I found something that's a little different, but it still took the neighborhood as the unit of health. So in the Singapore case, a few things mattered before they ever got started. First of all, Singapore reorganized its healthcare system such that it created several entities that basically had a place basis. So therefore, when we talk about issun, it's part of part of a larger organization or a network of organizations. And it had responsibility through the hospital for a certain geography. So one thing, it was geographical. In the United States, you have very little health care focused on geographies. The second thing is they were being paid in a way. They gave them an incentive to think about how could they do things differently because it would have an impact or nonprofit. Actually they might be for profit. So excuse me about that. I actually didn't spend a lot of time thinking about their legal situation, but I did spend some time thinking about why they had an incentive, because this is what's so lacking in the United States. They had a clear incentive because they were being paid, ah, in a certain way, and their costs were rising because Singapore is an aging society. And they were basically actively encouraged. This would be the third level. It became a national policy to push health care organizations in Singapore. And Singapore is quite different. It's an island. It only has several million people. Uh, I don't know the exact number, but let's say 4 or 5 million. We're talking about a country with 80 times as many people. And therefore you have, uh, something with the geography, you have something with the financial incentive, and you have a government pushing the organizations in the sector to think differently, especially about how do you affect, as you just said, the social determinants. Could we do something, invest in social determinants so that the one of the five, which is the health care cost, would go down by spreading the money in a different way? I mean, basically that is what they were trying to do. So you had this backdrop and that would be level one. The more what we might call the big picture at the local level. Again, when they started they had a vision, I'm not quite sure they had a full roadmap. They had to learn by doing because there wasn't really a clear roadmap how to do this. And basically they had several stages, which is what you're referring to. The goal was to nurture individuals in the uh, neighborhoods that they, they, that they undertook this change process. And we're talking, I forgot the level, but we're talking tens of thousands, but we're not talking millions of people here. They had a, they had a specific geography they work in. And they did this on a reasonable percentage of what they, what they uh, were responsible for. And the whole idea was to move people from, think that they were on their own and if they had a problem they would come and ask for help to the medical, to the, basically the hospital. What they were doing is they set up these nodes. Again, they put healthcare people into a role as facilitators, facilitators of relationships, facilitators of creating some physical landscape, some places, some habits. Because we're talking about places where people might go and do things together. We're also talking about changing habits, changing the way people interact with each other. And it was very explicit as this is what we used to do in the society. Again this is a very traditional society, very community oriented, family oriented historically. But the muscles about how we do that have basically not been used. And so they were nurturing through this multiple stages. Maybe I'm jumping ahead of here a little bit, but the idea was to go stage by stage. We're first we encourage people to come out and meet meat. Then we encourage people to gradually shape their environment. Then we gradually encourage people to take more of a leadership role. I mean, not sure that people would call it leadership, but it's basically them initiating, not waiting for something to start, but initiating that. Maybe we could reshape this corner into like the corner into a library. Maybe we can use this space for cooking classes or maybe we can. So the whole point was it was a several step process to nurture the trust, the habits, the locations, such that people would have much thicker relationships. Uh, some sort of mutual care would be part of this. But actually the whole habit of having agency and then knowing your neighbors and not being in your apartment and actually proactively making your places better. That in itself, it wasn't like mutually caring. It was the Fact that the change of behavior was making people feel better, made them happier, and made them less susceptible to actually getting sick. So as you could say, it was working on multiple levels. And the whole process was. I mean, you have very clear data in the article about how it changed that it made it less likely for people to show up and need care because they were better, they felt better. And by the way, they had people around them who could support them like with a web before they would ever come.

Speaker A: It's kind of obvious, but we forget that, you know, health starts in the home and then, you know, it's kind of concentric, you know, with mom and dad and you know, when you're young and then fans out into the neighborhoods. And so it makes sense they would do that and you know, and also kind of get that virtuous cycle going where, you know, uh, an example I gave in my book where we kind of got it right but then didn't get it fully right, is in La Crosse, Wisconsin, they put together a program called Respecting Choices to honor people's wishes at the end of life. Because it was really disturbing to the healthcare providers what they were having to do in absence of that information. And, and they ended up getting 96% of the community to have an advanced directive. And you know, people have different priorities. But as a nice byproduct, beyond the humanity of it, which of course matters the most. In the last two years of life, Medicare paid half of what they did, but unfortunately those dollars either stayed at, you know, UnitedHealth Care or some Medicare Advantage program or, you know, D.C. in the federal coffers when it should have been, you know, recycled and replenished in that local community to facilitate more flourishing. And you started to talk about the stage two where, you know, it shifts from a few programs to, you know, really an abundance of activities that almost anyone can find something that they like, you know, and as participation grows, you know, residents start new initiatives. And you know, one of the examples that I remember was the shoe cabinet bookshelf that turned into a community library.

Speaker B: Great example. Great. I asked them for the best examples and that was like the best example.

Speaker A: Yeah, yeah. And how did they get from kind of organized programs to some extent from the outside to this kind of self propelling resident initiated ecosystems. And you know, I'm curious what patterns you see in other places that also kind of cross that threshold. If you've been listening and thinking, I wish there were more places where people share what actually works. That's exactly why we created Rosettafest join us in Nashville at the end of July. It's where employers, unions and clinicians who've built thousands of health plan successes share how they improve the caregiver and patient experience that leads to the best health and financial outcomes. The only people on stage at, uh, Rosetta Fest have created sustained success and happily share their secrets, details and tickets@RosettaFest.org all right, back to the episode.

Speaker B: I mean, again, I live in a flourishing neighborhood and I'm amazed. I mean, it can be daily, if not, if it's not daily, it's weekly that I just see people doing things like, it's like everyone is activated. And when you live in a neighborhood where everyone is activated, I mean, I'm thinking on my street, I mean, uh, I'm in a neighborhood where, I mean, I have several people, several families or people that I'm close to, but there's hundreds of people I know I can at least acknowledge or say hi, um, but here I am on a two block street and on my street there's someone at 903 who goes knocking on the door of people living alone. And she's also doing the, organizes the cleaning up in the park. And sometimes she raises some, organizes people for a nonprofit. I'm thinking of my neighbor who's doing stuff down the street sort of for some school volunteering. I'm on the board of a special needs school. And my, the neighbor across the street, I mean Lily, he grew up here and it was four generations of his family here. At some point he still has a daughter in the neighborhood. And they started like a small charity. And then person next to him, they have six houses in the neighborhood that are all from the same, like extended family. And he's on, like on the board. Him and his wife are on the board of two other organizations. So again, going back to this example, it becomes something that becomes a cultural norm. And the challenge, if you're starting from zero, is how do you nurture this? And I think in the Yishun case, and we saw it in the other case a little bit different in that article, which was from Trieste in Italy, which was uh, more of a focused effort on the mental health. But in both cases, what was so interesting was the healthcare workers played a different role than we are typically used to. They had like something like nodes in the neighborhood. They played a role nurturing relationships. They played a role at some point connecting people. They tried to fill in gaps that were not filled otherwise, but they saw their role as facilitating nurturing community and then being Health care being like the backstop backstop, which is a completely different mindset than we currently have for health care. It seems almost binary. You're, you're well or you're sick, you're sick, you go here, you're well, you're. We don't talk to you, and there's no middle, when actually there's a continuum and, uh, an intervention. So in the Singapore case, again, you, you explained it, they created different spaces, they created programs. And once people began to get in the habit of knowing each other and going to programs and literally being to some extent proactively encouraged, that you have the, you have the freedom, you even have the opportunity that you don't have to wait for us, that you can go and do things. And it's almost like people click on. And I see it in my neighborhood, I go, I go five minutes away, and the houses are more beautiful and they are investing more in their lawns and whatnot. And yet nobody seems to know each other. And it's almost like there's an activation that changes the norm. And these healthcare workers, I mean, they're helping individuals who might have some constraint to participate equally because of whatever condition they might have. But once they've got past, we set up some places, we set up some programs, we encouraged people at the start, they did more proactive encouragement. But once people developed the habits, again you used the phrase, which I love to use, virtuous cycle. When we're disconnected and we are, I don't wanna use the word not caring for each other, but we're like autonomous and we don't have a thick relationship. We have a very transactional relationship with those around us. It creates like a collective action problem, a vicious cycle. And what they've done is they've nurtured this virtuous cycle through the multiple stages such that it feeds upon itself. Almost like as you in that background there, it's a bicycle that goes down the hill on its own. And that, to me, is the amazing magic. When you're in a strong neighborhood, you just see it and it's like magic after it gets going, it takes a while to get started, but it's magic once it's up and running.

Speaker A: It reminds me of, of a story. You know, some people are familiar with the mustard seed parable and how, you know, it's the smallest seed. And I find a lot of folks, whether it's in tech or in government, they really shy away from small, uh, you know, sort of things because they think they just aren't Significant enough. But when they're openly shared and they're replicable, you know, mean in part, meaning they're adaptable to, to the particular areas. You know, we, one of our community owned health plans that we've helped steward, you know, started with a single employer, you know, we're looking at through the employer lens. And then we had 38 employees, like not exactly Walmart. And you know, in a matter of three to five years we've seen multiple organizations where they're now serving tens of thousands, you know, in similar models, but basically the same structure. And you mentioned the provider, the healthcare system kind of stepping in and doing some of that. But a real sign of progress. She talked about stage two is when provider organizations, health hospitals start to remove themselves as the community's connecting work, as neighbors take over. How do these providers say in Singapore know it's time to step back and what that transition looks like, like and you know, what are some of the barriers to actually enabling them to step, step back when that flourishing is really kicking in?

Speaker B: I mean, again, I think when I write about this example, it's many, many years of learning about how this works. And I think the best way to describe that is again, they had a goal. I'm not sure how clear and specific they were at the beginning. And they took this as an experiment that this can make a tremendous difference, the lives of the people, the expenses that we have to pay for, and so on and so forth. And they had a direction, what would it be required? And I think what we see is that how they refine their model is they basically are as I described before, they start by again, you have so many people in the place and not everyone participates equally, not everyone has the same need. Some people are older, some people are professionals at work. But ideally they're trying to like in my neighborhood, more or less everyone is activated in some form because the barrier to entry is easy to contribute. To contribute. You don't, it's not like a high hanging, it's a low hanging fruit to do something, whatever it is, keeping eyes on the street. So there's, it's just, it's really easy to get started and it's so norm. So in this case I think there certainly is at the beginning much more proactive. But once you begin to see a certain critical mass, what's happening is they're moving from the more proactive stance to more identifying gaps, identifying individuals who need more assistance. And that assistance could be something that they literally need to help people on a regular basis because Maybe they can't move or whatever it is. I mean, uh, clearly if a neighbor can take them, um, in a wheelchair to participate, I mean, that would be the idea of the community. But at the beginning, what I wrote about in the article was there certainly are people who at the beginning need to be accompanied. Whatever that means. Doesn't mean that the person's always following you around, but accompanied you. So you get used to a, ah, new pattern. The idea is that you. You activate these people so they're comfortable, so they have some relationships. And the whole point is, again, it takes some experience and some training that you have some idea when you gradually step back. I actually don't know their metrics in terms of, like, participation rate and how they're measuring that. I didn't get into that much detail in the article, but I think what they're trying to do is certainly identify enough people who are not candidates to go to the hospital, of course, to have as many people in the neighborhood as possible to participate. But they certainly want to make sure people who have a greater need are engaged and involved with these activities. And again, some of the latter definitely may require a little bit more proactive action.

Speaker A: Yeah, you know, it's interesting. You talk about the accompaniment, and I'd say there's. When I look at patterns of success and goals and whatnot, there are some words that, you know, aren't foreign words, but I hear so much more now. Accompaniment, you know, is one you just mentioned.

Speaker B: I love that word. I learned it from, uh, in fact, a doctor who worked in Haiti, and that's what he called his work accompanying the Haitians. What's, uh, his name? The famous. Was it Paul Farmer? Paul Farmer, I believe his name. M. Yes.

Speaker A: Paul Farmer. Yes.

Speaker B: It's a word he used in his work in Haiti.

Speaker A: Yeah. And you mentioned flourishing as a goal. Love that. Another word I've been hearing a lot is sovereignty. And, you know, Michael Fine is a physician, you know, and public health leader in Rhode island, and he wrote a book called On Medicine as Colonialism, which is kind of the counterpoint to that, and used the colonialism metaphor of really what's happened in our health ecosystem where, you know, you think about what does a colonial power do. You know, they conquer territory, they extract resources, back to the mothership. In many ways, you can look at our healthcare system through that lens, as he did. What I've been working on that echoes some of the themes here that love to get your thoughts on. You know, there's some arenas where there has been a Sort of sovereignty self determination, you know, tribal self governance was really enabled through the Indian Self Determination act, the system I mentioned earlier, the NUCA system of care in south central Alaska. Really remarkable what's happened there. And then in, you know, a century ago, I would argue we have a market failure today with our healthcare system. Um, a century ago we had a market failure with rural America wasn't getting electrified. And so, you know, it's kind of DIY self determination initially where farmers, you know, set up their own cooperatives and kind of proved out a model, you know, from the 1890s into the 1930s. Eventually it was accelerated through the Rural Electrification Act. Um, and I think of those as kind of being precedents for this community self determination framework I've been developing. And there's both a diy, you know, just communities are doing this right without any, without waiting for wash in or state houses, but also one where there could be a legislative scaffold like the Rural Electrification act that could really accelerate some of these initial M models. Um, you know, neither precedent started with a federal program that was handed down. You know, both started with a community and a small number of people. I mean, I remember the first electric cooperative in Iowa's six farmers, you know, didn't even know where they were going to get the power and they put up power lines. Just anticipation. But, you know, there was some precedent there. Like they had that cooperative habit. There was a sovereign legal status with the, to tribal communities before the federal, you know, support arrived. So, you know, I'd love to get your take on, you know, the. You talk about some of like, where could this start? And one of the things not specific to healthcare that I think you did a wonderful job of in your book is like, just go find the assets, the unique things. It could be around a school, could be around some program. And then building off of that, you know, in our world we've had, um, things like the Wisconsin Employers Healthcare Cooperative. And you know, they started with just 300 employees at one school district. And you know, like, I don't know, three or four years ago, I think they had three that helped start this cooperative with 750 employees. Now it's at 23,000. Ashtabula county was the, uh, one I was alluding to earlier. Started with 38. And you know, they're doing these things today without any federal, you know, insurance backdrop or, you know, any particular legislation. But, but curious your take on this kind of DIY path. And you know, when do you think it can sort of reach its limit? Or do you think it's really, it will need legislative support or some kind of government support at some point?

Speaker B: Okay, I think there's several questions in there together. So when you're in a neighborhood like my neighborhood, and I would roughly guess in the United States, maybe 20, 25% of neighborhoods have a significant level of what we might call relational flourishing. I think it used to be much higher. And that's where we have the broad declines in all the data. But you still have some of these in all types of places, uh, geographies and cities, rural suburbs. And so places like my neighborhood, you don't have to wait for anybody because we're already doing it. I think the big question is what happens in the rest of these neighborhoods, um, places. And you generally have, you have places that are materially well off and just what I would call socially poor. Everyone is disconnected. And there's. And some of this is the way the neighborhoods are designed, the way the institutions are designed. And then of course, you have a whole nother category of places. And inequality in the United States is very marked by geography. Uh, neighborhoods have become very class based. And so you have this other category where even if the neighborhood people organized and got together, the question is, are they capable of. I, um, mean, certainly if they organized and they had the right institutions, it can make a big difference. But are they capable of moving the needle enough on some of the material changes? And so in terms of what you've. So we need, we need to keep in mind there's a great variety here, I think. I definitely am a believer that some sort of neighborhood centered governance. In fact, I've spent some time looking at what type of innovations, and I gave the Atlanta example. But, uh, I'm actually most interested. Is there something like a business improvement district model that could be done at the neighborhood level in which there would be incentives either for people in the neighborhood or people from outside of the neighborhood to change? Again, if you can create the right incentives, you would have more investment, more flow in these types of things. I mean, I can give the example because I did look and I mentioned you found an example. National Children's in Columbus, Ohio, has basically, basically been the best example I could find of a hospital or any healthcare provider taking a neighborhood approach. And how did that come about? Well, in the case of Ohio, they had a contract in which they were being paid something like what I described in Singapore. They are next to a neighborhood that was not doing well. Crime was rising, their employees were not happy, the neighborhood was decaying, and so they had this proximity factor, but also a good chunk of their patients were coming from that neighborhood and things were getting worse. And by the way, they had a contract, maybe uh, a 10 year contract or whatever it was in which they were being paid for certainly a certain amount of their business on a fixed per population amount. So they had a financial incentive, they had a staff retention incentive, they had, they had a bunch of incentives. There were also something to do with the mayor had an interest, you know, the governor. There's a lot of other things going on there which I think is beyond the scope of the call. But the fact is what they ended up doing was taking the neighborhood as the uh, as the patient. That's actually the phrase that they use, the neighborhood is the patient. And so their model is really different than Singapore. Singapore is about nurturing each of us as residents, as neighbors to take ownership of our place and our uh, on each of our health. And some of it's direct and some of it's indirect simply because we have these relationships and we're sharing and we're doing for each other and that's making us healthy. In this, in the Columbus case you're looking at that third category which is a neighborhood that was going downhill. Now the neighborhood has completely changed because of certain investments. And so I think there's a variety of things that can happen. One thing that's definitely necessary is healthcare needs incentives to basically have some ownership on the success of places. And that could be for I think hospitals and that could be for insurance companies. And again I'm not, it's your sector, it's not mine. But the more these in these organizations can see a return at their bottom line because a neighborhood got better and that can even be materially well off place in which the relationships are poor and therefore some sort of, there's some sort of downstream health care effect that would give them an incentive. And I've seen some insurance companies play with this idea. I've never seen them go all the way, but I can't find the hospital exempt. So one thing is that whole area, I think another whole thing you talked about, the larger question is could we invent some institution that was neighborhood centered that actually had again, could it be rises in property prices? Could it be that there's social something sort of equivalent to social impact bonds that the health gets better in the neighborhood and therefore everyone in the neighborhood gets some benefit from it? Again, I think, think I think of these things when you're living in a place as non material, it's just joyful. To be honest, life is more joyful, more happy when you're in these great neighborhoods. And that's why I'm so personally committed and motivated by the idea. But to the extent that we can create institutions that are more neighborhood stewards, that capture some of the value, whether it's increases in taxes or improvements in health, and I've seen different people play around and I do believe we can create some sort of innovations in some sort of legal entity in which improvements in neighborhoods leads to decline in health care, declines in policing, declines in maybe education, decline in social services. All of these costs could go down if a health care, if the health and the well being of a neighborhood goes up because a strong neighborhood will lead to a lot less costs. And health is maybe the most major, but it's not the only one. Even the government costs can go down and tax revenue can go up. And so there should be a way to capture all of this into an entity that therefore has an incentive with maybe some investment and you're getting the return. I think this, something like this, I don't know if we need new legislation, we need innovation. And I've heard various people working on this. I don't think the model has been perfected, but if somebody could create that, that would be an obvious way for it. And of course local governments, city governments in particular, or county governments, the more they think about it in terms of neighborhoods, the more they're going to spend their money wisely. That would be a uh, non healthcare example. Again you're thinking about where's the flow of money versus the results that we think that we want. And healthcare and government are the two biggest spenders that are basically not spending their money in places that matter. So true.

Speaker A: And I definitely won't claim we've perfected it, but that's very much what we're focused in on is creating those new entities. Because the reality you mentioned, the incentives with the big healthcare organizations, they simply don't have it. And one of the real unlocks for communities is when they realize that there's a river of healthcare money flowing through their community. And the source of that river of money is the pocketbooks of everybody in that community. It should work like a water cycle and replenish that community. Unfortunately, like in that colonialism metaphor, there's giant corporate pipelines that extract downriver of healthcare money, leaving the community in drought. And you know, the third chapter of my book was really spoke to what you're talking about, which is Economic Development 3.0 you could not have a tax break big enough to attract or retain a company that compared to if you're a high value healthcare community or a low value, far more than any tax break. Because for most organizations it's a second biggest cost after payroll. And you know, and that's where I thought the business improvement district analogy is really interesting because guess what? You know, who drives the business improvement districts in a community? I was once a city councilman. It's the businesses. What are those businesses? They're also employers, you know, in America for the, you know, for a long time Since World War II, basically employers provide healthcare, you know, more than Medicare or Medicare Medicaid combined. Even though a lot of them don't necessarily want to do that. Um, they are the real, what we have in our country is hundreds of thousands of tiny insurance companies. They're the ones actually carrying the risk, not the so called insurers that are really just expensive claims processors. And once communities realize that, then they can really reclaim that sovereignty. The other thing that's often forgotten in the different roles that governments can play at all levels is we think of them as a payer or regulator or public health. They are those things, but we forget they're also a very large employer. And I think about, we have employers in our community of all types, but a bunch of public sector where they are spending literally 20, 30, 50% less per capita with far superior health plans. And then that frees up money to the higher and better uses of that. And you know, there's been talks about public option, well you can call it the local option because when they open source it, then any other employer in their area can take advantage of those same provider contracts and primary care and drug coverage, all the things that basically, you know, make up a plan. So it's been exciting, you know, to see that. I want to be mindful of our time here because we could certainly go on a long time. It was a super interesting conversation, um, and want to kind of wrap it up around something that I thought was a really powerful three words purposely prescribed patients. You know, that was, you know, a phrase that you had in that article. And you know, people, you know, need the system less and less and the community can carry more and more. You know, if you're guiding a school board member, a civic minded employer, maybe a mayor who's listening. Um, you know, I found oftentimes the mindset shift is the biggest hurdle. Is there a particular mindset shift? You know, maybe it's just echoing what you've said, but what do you think is the biggest first step that they need to take to sort of put the, put things in the direction of these purposely unprescribed citizens approach?

Speaker B: Uh, let me say two things on that. Because we have so much got used to the idea of systems solving problems for us versus we solving problems together for our places. We have, I mean, I think social prescription, it's a good idea, it makes sense. But imagine we all were embedded in lots of relationships. You wouldn't need social prescription. Social prescript is a symptom of a larger problem in how we live our lives and how we actually go about trying to address our relational challenges. And I think a lot of our social challenges are at heart, they're called social problems because they're at heart relational. And so let me make that as a point in terms of what you asked about. How do you get started? I mean, for me, again, this, this is, goes back to the question in Singapore. How do you go from 0 to 10 on this, let's say, spectrum of high, like socially wealth, socially wealthy neighborhoods, or socially rich neighborhoods? And so again, if I'm making an argument about why it matters, I mean, the argument would be people are happier, more joyful, people are healthier, people are better connected to opportunity, there's fewer social problems. Kids are growing up with more responsibility and more prepared for adulthood. Uh, families are mutually supporting each other and don't feel so isolated and under pressure. I mean, just look at the things people care about. And so many, not all of them, of course, but so many of them would be, would be addressed or significantly ameliorated if you lived in a place in which there were loads and loads of social networks and interdependencies and local institutions who cared about the place. So that would be the big argument. How do you get started? Again, it depends where you are on the spectrum from 0 to 10. But I mean, at the beginning, I always tell individuals, this is more speaking to individuals. I say there's three ways you can get started. And I think the same thing would be if I'm speaking to someone at a larger scale, if I'm a government, or even if I'm a hospital, or even if I'm a community foundation, probably I would be doing something involving publicity with small grants. Because if you give grants of $500, a thousand dollars, and you use this money like lots and lots of little grants, the total amount you're spending is not going to be a lot of money. However, if each of those micro grants encourage people on a Block. To have a block party or a gathering or whatever it might be. And there's a whole bunch of ways you could design this. You could ensure that any grant was given to a group of people or everyone on your street or your neighbors. Or it could be just any 10 people in a geography. There's many ways to design this. It depends where you want to go. But that would be the simplest way to lubricate is some sort of publicity, especially around specific times of the year. And micro grants. Because micro grants removes a lot of the. I mean, people worry about cost. And if there's publicity in micro grants, again, you assume other people are going to do. It changes a lot. If I'm an individual. Going back to the three things, the simplest thing to do is just to start knocking on doors and trying to organize something. I'm just editing a piece now for my new platform about somebody from South Carolina I know who does, uh, potlucks. She grew up with potlucks. And then somewhere along the way, they stopped. And when she first did it, it was very awkward. But once you got in the habit of doing it, it just became like a tradition. And now other people do it. And that's one thing is that. Another thing is you can start just knocking on doors. Second thing is you can do something like a potluck. You organize things. You just have a bunch of neighbors. Third thing is work with some institution locally, in whatever form that might be. Look, again, institutions matter because they have. Tend to have a little more scale, a little more organization. Could be a coffee shop, could be a supermarket. Could be. It could be anything. It could be a nonprofit, it could be some charity. It, uh, could be a. I mean, again, it could be the library, it could be the local school. It could be a church. Any of them, they have space, they have capacity. Again, they don't have to do a lot, but they have some convening power, some resources, even if it's only space. And the more they're involved and the more neighbors are involved, that's how the virtuous cycle gets going.

Speaker A: No, that's great. And I loved your statement earlier. Maybe it'll be the title of this episode where neighborhoods is patience. I think just if you sit there in that and marinate in that and think about the implications of that, I think that's a really powerful, uh, framing. So as we wrap up, I'd love for you to share, you know, what gives you hope that the work you've been doing around flourishing neighborhoods from fragile neighborhoods, that gives you the hope that you have that this actually spreads. Given habits are always hard to change.

Speaker B: I mean, I have hope because I've had a really good reception to the book, to the. Again, if you ever find me, and I encourage people to find me on LinkedIn, have a huge audience there. We've just started the next stage, which is the substack, and so far, so good. So clearly people are hungry for this. People are looking for this. You see so many people. As you mentioned at the beginning, uh, I think we realize. I think at this moment in time, we realized that a lot of things that we've been doing, we've had a certain way of doing things for whatever many decades. They've reached the end of life. They cannot go further. Um, and it's creating frustration, but it's also forcing us to think positively. It's forcing us to rethink our premises, our assumptions, our ways of working. And I see this as an opportunity across many sectors and many ways of doing things as we need a different approach. And I do see a lot of energy, especially among young people, trying to find different approaches around some of these ideas. I'm hopeful because I think this frustration and this need for change and this positive energy, I see it all bubbling up. And I think the role that I see for myself, and maybe you see for yourself, is how do we nurture this? How do we identify things that are going in the right direction? How do we share knowledge, and how do we activate people? I think of my job as promoting good ideas, activating people.

Speaker A: Yeah, that's great. And we have seen that in my area, we had a convening of, you know, local folks who had kind of a stake in healthcare, a lot of employers, public health and public entities, nonprofits, uh, at a more individual level. In my neighborhood, there's called the Corner Taphouse. And, you know, we're in an area that, you know, Pacific Northwest. And you don't think of it as, you know, Nashville or Dallas or something in terms of something like line dancing. And, you know, it is just packed with young people. I mean, there's people in there, uh, you know, from their teens through probably late 70s, who are jammed into this taphouse to just have some of that in person, fun together, building relationships. You know, my wife has gotten to know, you know, a special ed teacher and, you know, variety of different people she wouldn't have otherwise met. And I want to thank you, Seth, again. You know, you started from neighborhoods. For those watching video, I'm, um, waving the book Fragile Neighborhoods. Well worth a read and glad that Seth found his way to healthcare. You know, we've seen. I mentioned NUCA system. You know, they started from a community with the courage to. To own health and healthcare outright. We've seen Wisconsin employers that started with a school district. We've seen manufacturers, car dealers, you name it. Different starting points, but all pointing towards the same destination. A community that owns its own health keeps the value it's created instead of watching it get extracted. And, you know, if you're an employer, a public sector leader, a foundation benefit advisor, and if this has moved you, you don't need permission to start. Um, none of these organizations did, whether it was folks in Wisconsin or Alaska. Find the tools, find a starting point, the community of people who really want some change. And we're seeing it throughout the health Rosetta community. And it's getting open source through the Nautilus Health Institute. And I just appreciate everybody listening to this point to relocalizing health. And we'll see you on the next episode. Thank you.

Speaker B: Thank you, everyone.