When I first read the reports about some Silicon Valley billionaires wanting to start a new city, I figured, oh, it’s just a bunch of rich white guys wanting to take their toys and go to a new, better home. After all, they’ve seen what’s been happening to downtown San Francisco (or Portland, or Chicago – pick your preferred city).
The Jetsons' city as reimagined by Bing
Cities these days may be an what one expert calls an “urban
doom loop” – struggling to recover after having been hollowed out by the
pandemic. These so-called elites probably figured it’s easier to build
something new rather than to try to fix what already exists. And, you know, they may be right.
Now that I think about it, the same may be true of our
healthcare system.
The group, fronted by a mysterious entity called
Flannery Associates, has been busy buying up land outside San Francisco for the
past five years, spending a reported $1b for some 57,000 acres in Solano
County. The proximity of its purchases to Travis Air Force Base had
already raised concerns. Believed to be behind the group are a number of
well known tech names, including LinkedIn co-founder Reid Hoffman; former
Sequoia Capital partner Michael Moritz; venture capitalists Marc
Andreessen and Chris Dixon; Stripe co-founders Patrick Collison
and John Collison; Laurene Powell Jobs, Steve Jobs widow.
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| Rich white guys. Credit: Kats Weil/Unsplash |
It doesn’t help that earlier this year Flannery sued dozens of local landowners for colluding to drive up prices, or that they’ve been so secretive. John Garamendi, one of the area’s Congressmen, said: “Flannery Associates has developed a very bad reputation in Solano County through their total secrecy and mistreatment of generational family farmers.”
The group finally went public with its intentions last
week. “We are proud to partner on a project that aims
to deliver good-paying jobs, affordable housing, clean energy, sustainable
infrastructure, open space and a healthy environment to residents of Solano
County,” said
spokesman Brian Brokaw. “We are excited to start working with residents and
elected officials, as well as with Travis Air Force Base, on making that
happen.”
Most of the land is currently
zoned for agricultural use, so getting permission for residential or other business
uses will take some effort, which is why Flannery Associates is planning to
meet with local, state, and federal officials.
The New
York Times reported
that Mr. Moritz spearheaded the effort in 2017, sending out a note: “He painted a kind of urban blank slate where everything from design to
construction methods and new forms of governance could be rethought.” A
poll sent out last week to Solano County residents asked if they’d be in favor
of a ballot initiative that would “include a new city with tens of thousands of
new homes, a large solar energy farm, orchards with over a million new trees,
and over 10,000 acres of new parks and open space.”
What’s not to like?
If this is going to be another enclave of rich people,
then I hope it never gets off the ground, after burning off lots of their
money (not that they’d miss it). If they’re sincere about having a diverse city,
all incomes and racial/ethnic backgrounds, then I’ll be watching closely. They
have a chance to build new infrastructure (hint: include robust wastewater
monitoring!), ensure safe and affordable housing for all, use renewable
energy, design it for walkability, and fill it with plenty of green space. They
could hire the good people at Building H
to help “build health into everyday life.” And if they really want to impress
me, they could even replicate/expand on Stockton’s universal basic income
initiative.
But what are they going to do about health care? What’s the point of building a 21st
century city from scratch only to overlay it with our 20th century
healthcare system -- the notoriously frugal Medi-Cal program, scads of employer
health plans, and ACA individual plans, not to mention Medicare/Medicare Advantage
for any seniors who happen to end up there. There’ll be lots of hospitals and specialists
who might see the new city as a great chance to make lots of money from all
those private pay patients. It will be our familiar mess.
No, if they want to do this right, they should rethink
health care too. Here’s a few ideas they should consider:
Universal coverage:
if you live in the community, you’re covered. No exceptions, no opt-outs, no
ineligibles. Think of it as their own
group health plan. They might need some
Medicaid and Medicare waivers to do this right, but they should make this the
first community where everyone is covered.
Wealth-based funding:
everyone should participate in how the healthcare system is funded, but not
through the inequitable premium system we’re used to but through taxes on
income, wealth, and/or property. No one
should ever be priced out of coverage (or care).
Health, not medical:
we always say “healthcare system” but what we mean is our medical care system.
It’s built around doctors, hospitals, and other medical professionals and
institutions. They’re all part of it, but they’ve become the tail that wags the
dog. Nutrition, exercise, sleep, social support, and so many other factors
contribute far more to our health. These shouldn’t be ancillary to the new
system but integral to it, with medical care what happens only when those don’t
suffice.
Primary care emphasis:
the system should focus on recruiting (and retaining) enough primary care
physicians (including OB/GYNs and mental health professionals) that waits are
nominal, visits aren’t rushed, and primary care is the main locus of care.
Forget traditional fee schedules/salaries; make income for primary care commensurate
with its value.
Tech enabled:
the Silicon Valley folks should love this: the system should be designed around
the latest tech – e.g., virtual care. real-time monitoring (e.g., wearables),
AI support, and so on, along with proactive Big Data analysis and recommendations.
And do better than Epic!
Hospitals:
to be honest, I’m not sure there should be any hospitals, at least not
initially. Don’t build any big buildings that become capital sinks. Maybe let
the Johns Hopkins (or other) experts design a Hospital At Home program that suits
the community, keeping people in their homes. Only build physical hospital(s) when
the population warrants it, and even then build them as small as possible. And
certainly don’t let them employ physicians.
That’s not an all-encompassing list, but it’s a start.
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| That looks like 21st century care. Credit: Bing |
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I’m not holding my breath that Flannery Associates
will build their new utopia, but, let’s admit it, they have a better chance
than they do to create a 21st century healthcare system.
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