If Tocqueville were to witness all these contemporary American scenes, he might say that Americans are people who still like to tackle problems in a group-undertakings that may loom small in the great scheme of things but large in the lives of those they touch. At the same time, though, the Frenchman probably wouldn't be surprised to learn that many of the volunteers in these modern tableaux weren't entirely motivated by altruism. They were also earning modest chits that they could later cash in for similar services. As with members of today's frequent flier airline programs, these volunteers were in some cases trading work for credits that could be used to book trips, pay car insurance premiums, or even buy vitamins out of a catalog.

This, too, would have struck Tocqueville as a familiar aspect of American character. In the United States, he wrote in Democracy in America, "all the members of the community are independent of or indifferent to each other," so that "the cooperation of each of them can only be obtained by paying for it."²

A century and a half later, we can marvel at Tocqueville's grasp of these seemingly contradictory aspects of American life: the love of community alongside the pursuit of self-interest. Indeed, that very duality lay at the heart of The Robert Wood Johnson Foundation's decade-long experiment in service credit banking-systems in which volunteers provided supportive services for frail elderly people in exchange for credits entitling them to similar services, or even to goods. The Foundation organized and largely financed this experiment in two distinct phases. From 1987 to 1990, it helped to run demonstration projects at six health care organizations, including hospitals and a nursing home. Then, from 1992 to 1999, it did the same with programs at six health maintenance organizations, or HMOs.

These experiments were designed to test the notion that systems of service credits could help narrow some of the yawning gaps in long-term care. In the end, both sets of experiments were closer to being failures than successes. Of the six programs launched at HMOs, for example, only two survived beyond the end of Robert Wood Johnson Foundation funding. As of 2001, only one was still allowing volunteers to earn and bank service credits-the other having turned into a plain-vanilla volunteer program in which people helped other people just because they wanted to.

Even so, both phases of The Robert Wood Johnson Foundation's experiment-and especially the second, formally called Service Credit Banking in Managed Care-shed light on a key question: what will it take to reorient American society so that it can meet the financial, organizational, and other demands of caring for legions of people who are frail and old? This issue is significant now, and it looms even larger for the future.

As of 1995, nearly 13 million Americans reported long-term care needs.³ According to one recent study, family and friends of those with chronic disabilities are already supplying them, gratis, with the equivalent of almost $200 billion a year in services-helping them eat, bathe, go to the toilet, shop for groceries, balance their checkbooks.⁴

What's more, that sum is on top of roughly $150 billion a year that individuals, private insurance, and public programs shell out on nursing homes and home health care. With outlays of support and dollars already so large, it's anyone's guess what they will be by 2040. Demographers project that by that point there could be anywhere from 59 million to 92 million persons over 65 living in the United States (versus 35 million at present), and anywhere from 8 million to 21 million persons age 85 or older (versus 4.4 million today).⁵

One thing seems certain: there is virtually no way that formal programs-and taxpayer funding of them-will be enough to satisfy the full range of needs of tomorrow's frail elderly people. This means that a good share of those services will have to be provided informally-by families, friends, or others giving care more or less out of the goodness of their hearts. In the age of big-screen TVs, gated subdivisions, and other barriers to civil society, how can we create surrogate communities of caregivers where none really exist? How can we mobilize people so that they not only notice that the poor old lady across town can't get out of bed-but so that they actually hop in the sport utility vehicle and drive over to take out her garbage, hold her hand, rake her lawn?

Could the answer possibly lie in something as arcane and unfamiliar as service credits? Would that same SUV driver, or anybody else, for that matter, really find value in accumulating small rewards for volunteering? To understand why The Robert Wood Johnson Foundation thought the answer might conceivably be yes, we need to pay a visit to the father of the service-credit concept-a septuagenarian named Edgar Cahn.

Cahn's Washington, D.C., home is cluttered with paper and stacked high with boxes. That's in large part because it's also the home of the tiny in-house think tank he founded, the Time Dollar Institute. Cahn is an attorney, an economist, and a long-time social activist-a veteran of the 1960s War on Poverty and a friend of the consumer activist Ralph Nader. Having served in the Justice Department in the '60s's under Attorney General Robert F. Kennedy, he later went on to help found the Legal Services Corporation, the government-sponsored entity that provides attorneys for disadvantaged people. As Cahn recounts in one of his books, No More Throw-Away People, he viewed his vocation as fighting for others and changing the world.

In a recent interview, Cahn noted that the first phase of his social activism was motivated by a classic progressive belief that "you could use rights and advocacy to get a more equitable distribution of goods and power." But in mid-career two events challenged the underpinnings of his activism and ultimately changed its course. The first event was a major heart attack that destroyed much of his coronary capacity and left him languishing for weeks in a hospital, tended to by a retinue of roughly 20 doctors, nurses, and other caretakers. "In the hospital," Cahn says, "I learned that the helper always feels good, but the helpee doesn't necessarily feel validated or affirmed. I realized that I didn't have an identity except as a recipient. You don't feel special to others when you're in need of special support and help."

The second wake-up call followed efforts to kill or scale back funding for the Legal Services Corporation in the 1980s. Cahn noticed something peculiar at congressional hearings around that time. "Not a single client family," no one who'd been helped by Legal Services, "showed up to fight for it." The lesson? "The unilateral giving of vital services doesn't alone create a constituency for a healthy society," Cahn says today. "I think we send the wrong message inadvertently when we help people."

The result was Cahn's conversion to what was almost a neoconservative perspective-closer to the insight of a welfare reformer than to that of the Naderite redistributionist Cahn had once been. He needed an idea to link together several realities: that there were lots of people in the world who needed help. That helping them could in some ways disempower them. That to keep them feeling empowered and engaged, he needed to enlist them in helping themselves. That conventional voluntarism didn't always motivate people, because it didn't always reward volunteer work for what it was-real work. "The solution, when I hit upon it, seemed obvious," Cahn writes. "Why not bank time spent helping others-something like a blood bank? Help somebody. Give an hour, get an hour. One hour equals one service credit."

Cahn thought then, as he still believes now, that the idea would be especially applicable to elderly people. If a group of comparatively healthy elderly people could earn service credits for helping others worse off than themselves, the world would be better in several respects. Elderly helpers would not feel like useless throwaways, having been rewarded for their volunteer work through service credits. Meanwhile, the "helpees" would get the service they needed, whether it was a ride to a doctor or a lifeline against loneliness. And finally, even these helpees would know that they, too, had the option of performing at least some services for others, however minimal, much as the housebound and seriously ill woman in Virginia made phone calls to cheer up others. In the process, they, too, could earn credits and escape the debilitating downward spiral of dependency, or the sense of being a throwaway person. Helper and helpee would be connected by a sense of reciprocity: "I need what you can do in the world as badly as you need what I can do for you."

At the suggestion of his friend Nader, who thought the "service credit" terminology too clunky, Cahn eventually came up with an alternative phrase: time dollars. Today, he helps to promulgate interest in the concept and support dozens of time dollar projects around the world. One that he helped set up in Florida came to the attention of Rolando Thorne, a program officer at The Robert Wood Johnson Foundation, who in turn brought the idea to his boss Jeffrey Merrill, who was then a vice-president at the Foundation.

The Foundation had been looking for ways to support and broaden informal assistance to seniors-a quest that, among other things, would some years later lead it to authorize up to $100 million on a separate program called Faith in Action to help churches, synagogues, and other faith institutions support their own members who needed long-term care. The notion of service credits seemed appealing in several respects, Merrill recalled in an interview. First was the idea of "getting services to people-a plumber coming in to put rails up in your bathtub, or a carpenter to secure your carpets so you wouldn't fall." Second, and "even more intriguing," Merrill said, was the notion that elderly people themselves could provide services-and that as a result, "this was a way to make them feel useful, and give them more meaning in life." And, third, "we were just floundering around for alternative financing mechanisms" for long-term care. In that context, service credits were "sort of a catchy idea."

Sensing that service credits could play a role, The Robert Wood Johnson Foundation board eventually approved the two phases of the program. The first phase, Service Credit Banking for the Elderly, authorized $1.2 million in grants for demonstration projects at six health care organizations: two hospitals, one nursing home, a senior center, a community service center, and a social health maintenance organization, or social HMO. During the program's run, from 1987 to 1990, Cahn served as an adviser. According to Robert Wood Johnson Foundation documents, the project was designed to answer three questions: would a program of service credits attract senior volunteers to serve elderly people? Precisely how important were credits themselves in this process? And could the concept increase local capacity to provide supportive services to frail elderly people?

At the end of three years, the answers to these three questions were, in effect, "Yes," "Not sure," and "Maybe." These conclusions were reached by Judith Feder, Julia Howard, and William Scanlon, three health policy experts affiliated at the time with the Center for Health Policy Studies at Georgetown University School of Medicine in Washington, D.C., who evaluated the program. They found that the programs had been effective in attracting people who were volunteering for the first time-not just "stealing" volunteers away from other programs. What's more, the programs had also accomplished a key objective in attracting elderly people to help others their own age.⁶

The evaluators spent a great deal of time and energy wrestling with how intrinsic the service credit concept had been to the success of these volunteer programs. The evidence, they concluded, was mixed. If anything, the weight of it suggested that the service credits weren't crucial either for attracting volunteers or for keeping them in the program. For example, in a survey that the evaluators conducted, only 13 percent of the volunteers said they were participating in the program to earn credits. By contrast, 64 percent said they were participating "to help others."

In the language of social science, the evaluators eventually wrote in the Journal of Aging and Social Policy that service credit banking organizations were "better understood as community membership organizations than as mechanical exchanges."⁷ In plain English, they were even blunter. "We thought there was a lot of confusion about the value of the credits," Judith Feder recalled in a 2000 interview. The credits' role as a medium of exchange seemed overblown; if people really needed some incentive to help others, the evaluators concluded, good old-fashioned money would probably work even better. At best, they believed, the credits were little more than a tool to promote voluntarism-and in some instances, not all that effective a tool, either.

What's more, the evaluators had also discovered that in many cases the service credit banking programs weren't doing an especially good job of service credit banking-that is, of keeping track of credits as volunteers accumulated them, or of debiting volunteers' accounts when they cashed them in. "The more you thought of these programs as real banks, the less sense it made," Feder said.

Feder and the other evaluators noted other difficulties with the service credit banking organizations as well. The programs had trouble recruiting both volunteers and service recipients. They encountered a mismatch between the services older people wanted, like transportation, and the ones that volunteers were willing and able to provide. A sizeable staff was needed to recruit and manage volunteers, maintain their enthusiasm, keep tabs on those who needed services, and run the computer hardware and software that was designed to keep the whole system functioning. Moreover, because the programs didn't generate revenues and usually weren't a core piece of the sponsors' organizational missions, they were viewed as expendable, especially when difficult financial times hit. In fact, within several years after the project ended, only two of the original service credit banking programs for elderly people had survived in something close to their original form.

All that might have been enough to cause The Robert Wood Johnson Foundation to throw in the towel on the service credit concept. But the problem was this: even if service credits didn't flourish everywhere, there were at least a handful of places where the programs built around them did survive and prosper. What's more, the success of such programs was often quite impressive, and it was clear that they were delivering important services to frail elderly people that weren't being delivered elsewhere. A case in point was one of the original Service Credit Banking for the Elderly grantees, Elderplan.

Based in Brooklyn, New York, Elderplan was one of the original social HMO demonstration projects created by the federal government in the 1980s. The concept behind social HMOs was to help frail elderly people stay out of nursing homes; to achieve this, social HMOs were given waivers from the traditional Medicare and Medicaid programs, in return for which they would offer supplemental services beyond the normal benefits that these programs typically offered. The concept provided a kind of natural home for a service credit program, in that social HMOs tended to attract both enrollees and staff members attuned to the importance of providing more than just standard medical services to the aged.

At the time The Robert Wood Johnson Foundation put out its call for service-credit proposals in 1987, Dr. Dennis Kodner was the chief operating officer of Metropolitan Health System, the nonprofit health system that was the parent company of Elderplan. He knew Edgar Cahn, was already a service credit or "time dollar" enthusiast, and directed his staff to apply for a grant. Soon after, an energetic young woman named Mashi Blech joined the plan as its first and (to date) only director of the service credit program, Member to Member. As of 2001, the program was still going strong, having delivered more than 120,000 hours of services to 6,000 people over the intervening 14 years.

Just recounting these statistics, however, fails to capture the degree to which the service credit banking program at Elderplan made a difference-both in the lives of enrollees, as well as in the survival of the broader social HMO wrapped around it. As Blech described it in a 2001 interview, many of the frail elderly people already enrolled in the Elderplan were being visited in their homes by personal care workers, who would offer assistance with such activities as bathing and toileting. Member to Member volunteers were able to augment these services with others that the personal-care workers weren't authorized or paid to perform, such as shopping or getting a ride to the doctor. That fact alone ultimately became a selling point that helped draw enrollees to the 8,000-member social HMO, said Blech. "With all the negative publicity that managed care companies get these days, Elderplan's marketing department is able to say, we're different. What other health plan would fix your leaky faucet?"

Far more than just a service organization, however, Member to Member became a living testament to the power of community-building. Members referred to the people they served as "partners," not as clients or cases, and the tales of the nearly heroic deeds some have performed testify to the caring attachments formed. Blech told of members who walked two miles through two feet of snow to make sure a "partner" had food in the house. Another-a 91-year-old woman deaf and mute since birth-was living a life of isolation and unsanitary conditions in her own home until she became the partner of volunteer Anna Colarusso. After Colarusso won the woman's trust, she virtually transformed her life-in part by persuading her to allow personal care workers into her home to provide her with needed services.

Over the years, the Elderplan time bank expanded into a range of other activities as well. Volunteers were trained as peer counselors and certified to provide education and self-help techniques for managing Alzheimer's disease, arthritis, and other conditions. As of 2001, one member, Rosalie DiPietro, was regularly leading an early-morning walking club for older people at a Brooklyn shopping mall. Others of the 200 active volunteers were engaged in activities such as conducting exercise classes by phone-calling as many as 15 other plan members at a time and coaching them through a preset exercise routine.

As Member to Member volunteers accumulated credits, Blech and her staff assembled an array of services and benefits into a package called "Credit Shop." Members could redeem credits from the catalogue for luncheons Elderplan sponsored throughout the area; bus trips for a day at the casinos in Atlantic City, New Jersey; movie theater tickets, or even a range of health-related products such as blood pressure monitors. What's more, for a number of years, members could use time dollars to defray part of the monthly premium for Elderplan until it eliminated the premium altogether in 1995.

By 2001, as Elderplan expanded its service area beyond Brooklyn and into the neighboring New York City boroughs of Staten Island and Queens, the reach of the Member to Member program grew along with it. "Our leadership had the vision and appreciation of what we had accomplished and decided to fund us fully and allow us to expand," Blech said. That sense of commitment from Elderplan's top administrators was an ingredient in other successful time dollar experiments. The top-level support of service credit banking at Elderplan was pronounced enough to provide a clue to Robert Wood Johnson Foundation officials as to what such other organizations would need to survive.

As the Service Credit Banking for the Elderly program wound down in the early 1990s, officials at the Foundation decided to take another tack. They believed that service credit banking organizations could be made stronger and more effective if created in an environment naturally disposed to give them institutional support and sustainability. That's when Nancy Barrand, then a Foundation program officer (and now a senior program officer), began to think about building on the experience of Elderplan-and conceived the notion of housing service credit programs in traditional HMOs around the country.

The moment seemed propitious. At that time, in the early 1990s, managed care seemed like the wave of the future in health care. Enrollment of Medicare beneficiaries in managed care organizations was growing rapidly, approaching 1.7 million in health plans nationwide. Barrand and other Foundation officials believed that managed care organizations might have the financial incentive to make service credit banking work, since supportive services that helped keep elderly people healthy and independent would probably also help to hold down costs. They also thought managed care organizations had the managerial depth and information management capabilities to keep service credit programs up and running.

In 1992, the Foundation set up a national program office for what would become the second phase of its experiment-the Service Credit Banking in Managed Care Program. As with the earlier phase, the program office was housed at the University of Maryland Center on Aging in College Park, Maryland. The director was Mark Meiners, an economist and long-term care specialist.

A search quickly began for a managed care organization that could serve as a pilot site. The first candidate was the Family Medical Group, a primary medical-care group practice in San Fernando Valley, California, that had contracts with three local HMOs. But at about the same time, Family Medical Group became the target of complaints that it was delivering inadequate care to patients. In an episode that foreshadowed later volatility at other managed care organizations, Family Medical Group lost a large HMO contract and half of its patient base, was sold to a medical management organization, and discontinued the service credit banking project.

The resulting quest for still another pilot site led to a Colorado HMO. The Rocky Mountain Health Maintenance Organization, based in Grand Junction, Colorado, was a nonprofit HMO with a commitment to serving its members, who numbered roughly 55,000 in 1993. About 8,500 of those members were 65 or older and very much in need of the types of support that service credit banking could provide. More important, Meiners says, the HMO was run by "people who wanted to make something happen."

There is an old joke about HMOs that says they have gone from being a Communist plot to a capitalist conspiracy in just two decades. In a tongue-in-cheek way, the line captures the remarkable transformation that took place as an essentially social movement within health care morphed into the multibillion-dollar managed care industry. Back when the social movement took off in the 1970s, many of the pioneers who founded HMOs did so out of a belief that they were all about preventing and treating illness, not just about cutting costs. Many saw their organizations not so much in terms of dollars and cents as in terms of building healthy communities. One HMO of this sort was Rocky Mountain. It was a place where seven-figure executive salaries were verboten-and where the original chief executive officer, Mike Weber, came on board in 1974 and was still at the helm more than 25 years later. As such, it was fertile ground when the seed of service credit banking eventually fell into it.

That happened almost by accident one day in the early 1990s. Art Crumbaker, now in his 70s, was a Grand Junction, Colorado, internist who had been one of the founders of Rocky Mountain HMO in 1972. His wife, Lucy, had read an article about service credit banking in a magazine that mentioned the earlier Robert Wood Johnson Foundation-funded experiment. She passed it along to her husband, who was interested. "I had a big geriatric practice, and I could see that there were a lot of people who could use help,"he said later-whether it was getting assistance in going to the grocery store or having a volunteer handyman come in to build a wheelchair access ramp. Crumbaker thought a service credit banking arrangement would complement the Rocky Mountain HMO's other activities, and mentioned it to Weber.

Weber immediately agreed. "What struck me was that this was a logical extension of filling the needs of that [elderly] population," he recalled in an interview. The concept also fit in well with the mission of Rocky Mountain HMO. "The philosophy of Rocky Mountain had always been to try to do what's right for a particular patient," even if it went beyond providing services not traditionally thought of as health care benefits. Moreover, Grand Junction itself, situated on Colorado's Western Slope and surrounded by mountains, was a city whose geography seemed to reinforce its strong sense of community. A culture of voluntarism was already thriving: for example, a prominent local businessman and friend of Crumbaker's, Art Moss, had helped to set up a senior day care center at a local church along with other voluntary services for older people.

Weber and others got in touch with Mark Meiners, and in 1993 a three-year contract was signed to develop a time bank. The Robert Wood Johnson Foundation and Rocky Mountain HMO would each contribute $50,000 a year to the project for the first three years. The program would be housed within Rocky Mountain HMO's home health care agency, and would work, where possible, to provide services for the agency's clients. Although volunteers didn't need to belong to the HMO, only HMO members would receive services. This structure and limitations on who would obtain services was considered a temporary necessity in order to get the program up and running. The larger, long-term goal shared by Weber, Crumbaker, and Meiners was to take the time bank "into the community," as they repeatedly described it. In other words, they wished to move it ultimately beyond the walls of Rocky Mountain HMO, so that the time bank would include all of Grand Junction, drawing volunteers and service recipients alike from surrounding Mesa County and serving the entire community's needs.

The HMO set about laying the groundwork for operations and recruiting a time bank director, who arrived in 1993. Diane Dickey, previously employed at a local hospital, seemed to be the sort of enthusiastic and determined powerhouse Rocky Mountain HMO officials thought was needed to make the program fly. Their judgment proved correct. Dickey immediately began recruiting volunteers, visiting local service clubs and church groups, going "anywhere anyone would invite me," she recalled in an interview.

One of the first places she visited was the Hilltop Rehabilitation Center in Grand Junction, which held a monthly luncheon for senior citizens in the community. In attendance that day was Ted Rodda, who had just retired as an engineer for Hamilton Sundstrand Aerospace in Grand Junction, and his wife, Rita. They were interested in Dickey's description of the time bank, and decided to sign on. After a few training sessions, they were in business as two of the time bank's first volunteers. The Roddas were not members of Rocky Mountain HMO, and so were under no illusion that they would ever be able to cash in credits to receive services. Rather, they recalled in an interview, they had a simple motivation: they wanted to help people. Ted Rodda, in particular, felt strongly about helping elderly people stay in their own homes as long as possible. "I just get a warm fuzzy feeling out of it," recalled Ted, who was born in 1927.

One of the people who became a beneficiary of the Roddas' altruism was a woman in her 80s named Bernice Burnhart, a widow whose husband had died 15 years earlier. She was legally blind and had to use a walker. "Nothing had been done to her yard for 15 years," Ted Rodda recalled, so he busied himself with her yardwork and such tasks as cleaning out the freezer. Rita helped Burnhart keep her financial affairs in order and also did the grocery shopping. As was often the case in service credit banking programs, an initial "date" between volunteer and recipient turned into a kind of a marriage. The Roddas continued to do volunteer work for Burnhart for the next two years, until her death in 1995. Clearly, a bond of friendship had developed alongside the giving and receiving of services. Says Ted, simply, "It was just a good fit. Everything seemed to go well."

As of 2001, some 8 years later, the Roddas were still volunteering for the time bank, and said in an interview that they didn't intend to give it up anytime soon. In that respect, they were typical of most of the volunteers in the program, since most stayed on for years with very little turnover. "We used to say people died to get out of the time bank," recalled Marie Schmalz, who succeeded Diane Dickey as director of the program when Dickey left Grand Junction for several years in the mid-1990s. Over the years, the volunteer ranks swelled. The local Rotary Club wanted to volunteer as a group, so they were commissioned to do yardwork. Some Rocky Mountain HMO staff members became volunteers, including Dr. Mary Clark, who also served as the time bank's medical adviser within Rocky Mountain HMO. "I pulled weeds for a lady with a breathing problem who had had a beautiful garden that had gone to waste," she said in an interview. "It made her so happy. She didn't want anything else-just wanted her garden restored."

The time bank also began to fulfill its intended function as a bank, in which people could volunteer and accumulate credits that they hoped to use later. Some senior citizens, for example, signed up to earn credits so that their spouses might be able to cash them in if they needed them someday. Among the first to both bank and draw down credits was actually a younger woman, Kathy Ireland, a Grand Junction schoolteacher in her early 30s. A single mother with two small children, she had volunteered for the time bank just a few times but then broke her leg in a car accident. Desperate for some household help, "she called up half hysterical and said, 'I only have four or five credits to cash in and I'm going to need a lot,'" Diane Dickey recalled. The time bank director told her she could receive an "advance" on her credits in anticipation that she'd earn more as a volunteer later. Dickey paired Ireland up with volunteers who pitched in with household chores and errands until Ireland recovered.

Because the time bank was set up within the home health department of Rocky Mountain HMO, as many as half of its referrals came from individuals who were receiving home health services, such as nursing visits, bathing, feeding, and other personal care. These people usually had other needs that simply weren't or couldn't be met by home health providers-for example, because particular services weren't covered by Medicare or Medicaid. This was where the services that could be performed free by time bank volunteers proved to be a godsend, said Donna Vogel, a medical social worker with Rocky Mountain HMO's home health agency. "No other group would do something like fix a broken light switch," Vogel said, noting that the cost of hiring an electrician to do that could easily exhaust a senior's monthly budget for medications. Other volunteers built wheelchair ramps or filled out applications so people could obtain free medications through special assistance programs run by pharmaceutical companies.

Perhaps the biggest unmet need for frail seniors was transportation-to get to doctors' appointments, go grocery shopping, visit relatives in nursing homes. This was especially true in Grand Junction and vicinity, which until the late 1990s had no public transportation whatsoever. As a result, anywhere from half to three-quarters of the people who drew services from the time bank got them in the form of transportation-with volunteers shuttling them to their destinations, then waiting patiently to the end of a doctor's appointment or other engagement to take them back home. Some also took the people they were providing services to on long-distance trips at their own expense, just to give them a chance to get away.

To hear those involved with the time bank tell it, the program clearly succeeded in establishing and reinforcing the sense of community that Edgar Cahn had envisioned. At annual Christmas lunches and springtime picnics, volunteers were praised for their good works by Rocky Mountain HMO officials like Mike Weber. "I surely don't live for it," said Ted Rodda, "but it is nice to hear somebody say, 'You volunteers logged 4,000 hours last year.'" At one memorable picnic, Marie Schmalz recalled, one group of volunteers was honored with special certificates; they were "retiring" from the program because they were so ill they could no longer physically perform any services. At the same event, a woman who had been receiving services from time bank while fighting breast cancer, and on Medicaid, spoke about what the program had meant to her. The woman, Jean Kissel, had eventually recovered from the cancer, gone off Medicaid, and begun working again. As she expressed her gratitude for the time bank's help that day at the picnic, "She was crying and everyone else was crying," Marie Schmalz said. The human connections Edgar Cahn had sought had been forged, and they ran deep.

The program had also succeeded in bringing to life Cahn's vision of reciprocity. For example, people drawing services from the time bank were assured that, if they chose to, they could themselves volunteer to earn credits-a fact welcomed by seniors who seemed to feel guilty and over-dependent as a result of receiving assistance. That "helped to overcome the Depression-era mentality" many of the elderly people felt, said Donna Vogel-a mentality she describes as "I'm not going to pay someone to fix meals for me; I'll starve first." She described one homebound elderly woman, now deceased, who was for several years drawing services from the time bank but who also made regular phone calls to cheer up similarly situated seniors as a volunteer. Actions like these "made the recipient feel like they were giving back," Dickey recalled. "After a while, it wasn't always clear who was helping whom."

For all these personal successes, the program encountered serious difficulties. Running the Rocky Mountain HMO time bank was far from being a picnic. Diane Dickey and later, Marie Schmalz constantly struggled to reach a balance between the number of volunteers and the number of those who needed services. The goal was never achieved, and the latter usually outnumbered the former by around six to one. The time bank staff also labored largely in vain to get Rocky Mountain HMO physicians to refer patients to the program. Dickey reported meeting several times with the Mesa County Individual Practice Association, the doctors' group-at one point even handing out classic doctors' prescription pads imprinted with the time bank's name and phone number in the hope of jogging doctors' memories. "They were just so busy concentrating on the medical aspects of disease that they forget that when someone's discharged from the hospital, they won't be able to get their groceries," Dickey said. The result was that the time bank's services were never fully integrated into the spectrum of medical and social needs in the community.

Finally, although the time bank staff members felt strong personal and emotional support within Rocky Mountain HMO, they were consigned to working on a shoestring budget that, excluding salaries, was only about $50,000 a year. "My personal opinion is that we could have used a lot more monetary support to make the program more successful," Marie Schmalz said. In the end, the time bank was at least partly hampered by financial difficulties that faced Rocky Mountain HMO along with most managed care organizations in the latter half of the 1990s. Those strains made it impossible ever to consider expanding the program's budget, which in turn might have made it easier to enlist the aid of physicians or recruit more volunteers. As it turned out, the numbers of volunteers and people receiving services grew very little in its last few years of operation under Rocky Mountain HMO's auspices.

Eventually, these budget limits played a role in nudging the no-longer-fledgling time bank out of the Rocky Mountain HMO nest. That, of course, had been the longstanding dream of people like Mark Meiners, Mike Weber, and Art Crumbaker-and as The Robert Wood Johnson Foundation grant period neared its end in 1998, planning began in earnest about how best to reach the goal. Several organizations in the community were approached to serve as sponsors, but for various reasons they didn't seem right. Finally, the time bank officials began talking to the Mesa County Department of Human Services, which was receptive to the idea of taking the time bank under its wing. "They said, 'We've needed this thing for so long,'" recalled Diane Dickey, who by this time had returned to Grand Junction and taken another post with Rocky Mountain HMO. County officials immediately saw the possibility of marrying the volunteer program to other services that local government was already providing to Medicaid recipients, homebound seniors, and others in need. In September of 2000, the transfer took place. The time bank moved into the Department of Human Services' offices on the outskirts of Grand Junction, while Rocky Mountain HMO agreed to contribute $7,000 annually toward the time bankbudget for at least three more years.

As of the transfer, the time bank came under the leadership of a new director, Brenda Nelson, who among other things formerly ran a food bank and worked as a Girl Scout program administrator. She evidently inherited the fervor and commitment of her predecessors, Dickey and Schmalz. In an interview, she waxed enthusiastic about her plans to "take the time bank to its next level"-that is, to broaden the pool of people it serves, as well as the services and goods that could be claimed with credits. Nelson expressed the hope that the program could double in size through recruitment of new volunteers-especially middle-aged people with older parents, who might wish to accumulate credits that could be cashed in on their parents' behalf later. She hoped to encourage major corporations to give their employees time off to volunteer with the time bank. She also planned to allow participants in six other volunteer programs run by the county to accumulate time bank credits.

Nelson's most ambitious plans centered on expanding the types of services that volunteers could claim with the credits they accumulated. She pointed to another time bank in Durango, Colorado, where volunteers who earned 200 hours of service credits can cash in 20 of them for $1 apiece to help pay car insurance or child-care bills. She wondered why volunteers in Grand Junction couldn't have similar opportunities. Or how about a catalog like the one at Elderplan in New York, where volunteers could sort through products that could be obtained with service credits, from vitamins to other health-related goods?

Nelson's enthusiasm had helped to soften an inevitable sense of letdown that some volunteers-and even Rocky Mountain HMO staff-felt when the program was transferred to the county. Volunteers from the old program were encouraged to transfer their credits to the new one, and some 80 out of 125 did so. But others, demoralized and fearful of change, dropped out; some took the attitude that "I don't want to be involved in anything with the government," Diane Dickey recalled. But others were hanging in-motivated, it appeared, by the same sense of finding meaning in their efforts to help fellow human beings. Nelson recounted the story of telling one regular volunteer that she feared she'd been calling on him too much to assist other seniors. "Don't ever think that," the man replied. "Since I lost my wife, this is what's kept me going."

As the Rocky Mountain HMO pilot project picked up steam, in October, 1994, The Robert Wood Johnson Foundation authorized $750,000 for projects to replicate the time bank experiment at managed care organizations elsewhere. The goals were ambitious: the National Program Office was seeking organizations willing to attract anywhere from 500 to 1,000 volunteer caregivers over the five-year grant period. The initial response was enthusiastic, and the office received 118 requests for applications. However, about half the organizations that expressed interest didn't meet various other eligibility criteria. Ultimately, the National Program Office received only 10 completed applications by the June 30, 1995, deadline.

Five sites were eventually selected: Sentara Life Care Corporation in Norfolk, Virginia; Oxford Health Plans in Norwalk, Connecticut; CareAmerica Health Plans (now Blue Shield of California) in Woodland Hills, California; Washington State's Group Health Cooperative of Puget Sound; and Medica in Minneapolis. "We really had quite a good set of plans that stepped up to do this," said national program director Mark Meiners in an interview. But unbeknownst to the nation's most prominent health care experts, even the best managed care plans would have trouble surviving the troubles that lay ahead.

When the history of managed care is finally written, the latter half of the 1990s may go down as the era when everything went wrong all at once. Many managed care organizations that seemed to be on top of the world in the early 1990s came crashing down to earth as the decade neared its end. A case in point was Oxford Health Plans, one of the sites selected for a service credit banking project. Based in Norwalk, Connecticut, and founded by a one-time wunderkind named Stephen Wiggins in the late 1980s, by the mid-1990s Oxford had become the fastest growing HMO in America. Then Murphy's Law hit. Oxford's stock, once a darling of investors, skidded from around $70 to just a few dollars a share in a matter of weeks. The company began bailing out of its core businesses left and right, including many of its Medicare HMO plans in various states. Wiggins was ultimately fired by Oxford's board, but not before he walked away with a $9 million severance payment.

In an environment like that, it's little wonder that tiny volunteer programs like service credit banking failed to prosper. And that is exactly what happened at most of the other HMOs that wound up with service credit banking grants. Almost all these HMOs lapsed into turmoil, and were ultimately unwilling to sustain the service credit banking programs financially. For example, two of the managed care organizations, CareAmerica and Group Health of Puget Sound, either were merged or were significantly restructured during the grant period. Along with Oxford, Medica and Sentara scaled back or folded their Medicare managed care programs and shut down their service credit banking programs soon after. At Oxford, employees of the in-house service credit program showed up one day for work only to learn abruptly that much of the company's Medicare HMO business was being terminated-and as a result, the very base of their operation along with it.

Ultimately, only two of the service credit banking projects-Rocky Mountain HMO's and CareAmerica's-survived in any form whatsoever beyond the grant period. But neither of the HMOs that supported the two surviving projects were immune from the financial pressures afflicting managed care; Rocky Mountain in particular had encountered its share of red ink. The fact that the time bank survived there until 2000, while comparable programs at other HMOs didn't even make it that long, suggests that more than just the financial woes of HMOs was responsible for their downfall. In fact, the evidence suggests that commitment from senior management, and recognition that service credit banking was a valuable adjunct to the organization, were instrumental in keeping the surviving programs alive. When these were missing, the experiment was doomed to failure.

A case in point was the Sentara Volunteer Caregiving program, as the service credit banking experiment was called at the Sentara LifeCare Corporation. Sentara was a broad-based health system of hospitals, nursing homes, and physicians that also had an HMO with Medicare enrollees. After Sentara received the service credit banking grant, it recruited Leigh Hammer, the director of a local assisted living facility, to come over and run the service credit program. Housed within Sentara's LifeCare division, which operated the nursing homes and other eldercare activities, the program opened for business under Hammer's leadership in September of 1996.

Every bit as enthusiastic as her peers at the other service credit banking programs, Hammer set about the tough job of recruiting volunteers and devising a service-delivery program. It was a long, slow haul, she recalled in an interview. At the program's peak, it had a staff of no more than 160 volunteers, and served, by Hammer's estimate, just 235 people. That put it well short of the numerical goals The Robert Wood Johnson Foundation had set earlier for all the service credit banking programs. Even so, the program had developed some innovative services. Together with Sentara's home health department, Hammer helped fashion a program in which volunteers made follow-up telephone calls to children with asthma. The volunteers would conduct a telephone survey, asking whether the children were using their medications, whether they had had attacks that had necessitated visits to the emergency room, and other questions designed to ferret out whether the children were participating fully in their care. If problems were identified, a home health nurse would be dispatched to the child's home.

Although this "telephone reassurance" program was small in scale, Hammer estimated that it saved the HMO more than $100,000 just in averting unnecessary visits by home health nurses to gather similar information. Despite those savings, when push came to shove, Sentara was unwilling to invest further in the program-mainly, it seems, for lack of interest. "We made a presentation to [Sentara HMO officials] about what we were doing, and they said, 'That's real good, you take care of that over there'," Hammer recalled. "We were at a point where we needed to hire a second person, but there was no money to hire anybody else, so we couldn't grow." As a result, once The Robert Wood Johnson Foundation grant ended, in December of 1998, so did any commitment to keeping the service credit banking program up and running. Soon thereafter, Sentara's financially troubled HMO was closed down as well.

All along, Hammer was encountering additional problems that plagued the other service credit banking sites as well. Perhaps the most frustrating was working with special computer software that had been designed for the program. The software had two basic functions: to help match volunteers with persons needing services and to keep track of the accumulating service credits. The Foundation had commissioned various software firms to develop successive generations of the software to keep pace with the change in personal computer operating systems. But almost all the versions of the software turned out to be difficult to use if not seriously flawed-even after The Robert Wood Johnson Foundation invested nearly $42,000 in a final version. "The software was pretty useless," Hammer said.

Like most of the other program administrators, Hammer ended up doing most of the matching of volunteers and those needing services in her head, or with the help of records kept in a notebook. In a sense, such small-scale actions were only symbolic of much of what happened in the rest of the service credit banking program, as once lofty expectations settled down closer to the earth.

With the benefit of a few years of hindsight, it's possible to hazard a few judgments about what Service Credit Banking in Managed Care did and didn't accomplish-or what it did and didn't prove about the application of the service credit concept to long-term care. At a minimum, the initiative certainly didn't make a strong case that managed care organizations could be relied on as sustainable homes for such programs. After all, only a few of the service credit banking programs launched by The Robert Wood Johnson Foundation grants survived in some form into 2001, and they seemed in various ways to be more the exception than the rule. Leigh Hammer, who ran the Sentara program that didn't make it, argued that it would have been better off housed at a charitable organization with a strong commitment to public service-and therefore a desire to keep up the mission through thick times and thin.

Judith Whang, the Robert Wood Johnson Foundation officer who eventually came to oversee the program, wondered in retrospect whether the Foundation should have waited until the managed care market stabilized before launching the program. "The benefits here were marginal," Whang said in an interview. But she added that that doesn't mean the program was a waste of time or money. "The concept was fascinating enough that it got people to think about launching volunteer programs with different motives," she said. "One of the benefits of a foundation like this is to try ideas and fail-and it's okay."

"You can't point to what we've accomplished as a success," Mark Meiners agreed. "On one level, it bombed," mostly, in his view, because of the way managed care was falling apart across the country. But Meiners was far from willing to call the service credit concept a failure: "I think it's possible that it's not the way to go, although I'm really not ready to say that yet."

So what did the experiment show about the role of service credits? Were they effective in building the sense of community and reciprocity that Edgar Cahn envisioned? The consensus from participants is: yes, and-well-no.

Clearly, in some instances the credits were an attraction that piqued the interest of volunteers and helped induce them to provide their services. Even if they had no intention of ever cashing in the credits, it seems that many volunteers watched their credit balances like hawks. In almost all the programs, volunteers got periodic mailings listing the number of credits they had accrued-and "they would call you if their quarterly summary wasn't correct," Rocky Mountain HMO's Diane Dickey recalled. In her view, the credits functioned as a kind of glue that reinforced the human bonds that underlay the program. "I think you could have a volunteer program without service credits, but it wouldn't have been as successful," she said.

On the other hand, more volunteers than not, it seemed, were like Ted and Rita Rodda, the Colorado time bank volunteers at Rocky Mountain HMO. "The credits never mattered to us," Rita said in an interview-pointing out that, as non-members of the HMO, they could not have cashed in credits to use services. And even Marie Schmalz, who succeeded Diane Dickey at the Rocky Mountain time bank, has her doubts. "As far as I'm concerned, volunteers didn't do it for the credits," she said. "They may have started out doing it for that reason, but you give them a couple of good experiences and they forget about the credit." In other words, credits were at best a kind of hook-a gimmick-to get volunteers in the door. But they certainly didn't keep them there.

Still more evidence supporting this view comes from the one other program that survives out of the original six Service Credit Banking in Managed Care grants. That's CareXchange, the program launched at CareAmerica, an HMO that was bought by BlueShield of California in 1998. As of early 2001, CareXchange had roughly 400 volunteers and 840 service recipients scattered across five Southern California counties. But late in 2000, CareXchange made a crucial decision to dump the service credits and become just a standard-issue volunteer program-one in which volunteers perform services because they want to, and nothing more.

"I really didn't want to give the service credits up," said CareXchange's director, Mindy Morgen, who had written the original proposal to get the grant from The Robert Wood Johnson Foundation and once considered herself highly devoted to the concept. But what underlay the decision to abandon the credits was that administratively "it was a nightmare to manage them," she said. It took considerable amounts of staff time just to manage the banking functions of keeping track of the credits-so much so, in fact, that the program had actually stopped sending out statements of service credit balances to volunteers a few months after it began. Then, in November of 2000, a CareXchange newsletter to participants carried the news that the service credits were being officially dumped as of 2001. "We got no feedback at all" from the program participants, Morgen said. "No one wanted them anymore. No one cared."

So in the final analysis, are service credits or time dollars a concept whose time is coming-or merely a fringe idea, likely to play only the smallest of roles as society confronts the challenge of long-term care? A dispassionate evaluation of The Robert Wood Johnson Foundation experiments might tend to underscore the latter view, since so few of them have survived, and since even they are serving relatively small numbers of elderly people. From this perspective, it seems impossible to imagine a national time dollars program serving anything like the numbers of people likely to need long-term care services in the future. Rather, time dollars could be to long-term care what windmills and solar panels are to the nation's energy supply: a small, unconventional, even noble way of serving the few, but nothing to be relied upon to meet the needs of the masses.

Then there's the alternative view of service credit programs-that their time, if not already here, is coming. In a sense, they fall midway along the spectrum of options available to us as a society for providing long-term care. At one end, we could tax ourselves in order to pay others to provide care for our aging and frail loved ones. At the other extreme, we could freely provide all the care to our loved ones ourselves. In the middle are systems with the sort of dualism Tocqueville would have recognizedformal and partly informal caregiving systems, perhaps built around service credits, a kind of oxymoronic payment to reward the altruism of others. In twenty-first century America, where neither of the two aforementioned extremes seems possible, perhaps service credit banking programs could be a practical compromise.

Not surprisingly, the view that service credit banking has a future is shared by Cahn and other enthusiasts helping to run dozens of other time dollar programs around the world. The concept is spreading, Cahn argued, for the same reason other waves of social activism have taken off in the past: because "those involved feel they are somehow at the hub of a movement that can make a real difference in the world." The notion of a community coming together to meet its collective needs "resonates with people of vision because it speaks explicitly to global economics, to social justice issues on multiple levels: pragmatic, day-to-day, spiritual, policy, intellectual."

What's more, said Cahn, if time dollars or service credits didn't already exist, someone would have to invent them-since they are a proxy for the very thing that must be at the crux of long-term care. "I don't think we can crack long-term care in this country until we can figure out a way to create these informal support systems in a way we can depend on," Cahn said. "The operative word is community, which implies stability, but the reality of our present-day existence is flux. The mitigating intermediary is something called memory. If we can figure out a way to create the equivalent of family memory, community memory, institutional memory, we can figure out a way to crack the problem of long-term care." Or to put it another way: if you can build a community by proxy across three boroughs of New York City, as the Elderplan's Member to Member program is doing to this very day, perhaps you really can build it anywhere.

For all of the problems in administering programs built around them, then, service credits, in the best of all worlds, can become a proxy for vanishing memory. Perhaps it is a memory that conjures up for us a time in our Tocquevillian, mythic past when, we believe, people cared for one another more than we do now. It is, in any case, a memory of feelings that we ourselves may have felt as we've helped an ailing neighbor or placed a comforting call to a lonely friend. For it is at those moments that we've understood that we are connected to one another, that the connection matters-and that it will doubtless matter all the more to us as we age.