Poverty and health in the US

The US is the richest country in the world, but has some of the most entrenched poverty and associated poor health outcomes. Miriam Sabin (North American Senior Executive Editor at The Lancet) joins Jessamy to chat with Luke Shaefer (Professor of Public Policy at the University of Michigan and Director of Poverty Solutions) and Mona Hanna (Professor of Public Health at Michigan State University and paediatrician at Hurley Medical Centre) about why this is, their innovative Rx Kids cash grant program for families in Michigan, and what the upcoming US election means.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Miriam: Hello, and welcome to The Lancet Voice. It's October 2024, and I'm Miriam Sabin, the North American Senior Executive Editor at The Lancet. I am so pleased to be with you this week, co hosting with you, Jessamy. This week, we're talking about the United States in the lead up to the election. We are very excited to be speaking with Luke Schaefer, who is the Herman and Amalie Cohn Professor of Social Justice and Social Policy and Professor of Public Policy at the Gerald R.

Ford School of Public Policy at the University of Michigan. At the University of Michigan, he is also the inaugural Director of Poverty Solutions, an interdisciplinary presidential initiative that partners with communities and policy makers to find new ways to prevent and alleviate poverty. And Mona Hanna Attisha, who is the Associate Dean for Public Mott Endowed Professor of Public Health at Michigan State University College of Human Medicine.

Thank you She is the founding director of the Pediatric Public Health Initiative, an innovative partnership of Michigan State University and Hurley Children's Hospital in Flint, Michigan. Professor Hannah was named one of Time Magazine's 100 Most Influential People in the World for her role. In uncovering the Flint, Michigan water crisis, Professor Schaefer and Atisha will be discussing the important topic of how to alleviate child poverty in the U.

S. In a forthcoming health policy paper, in a special issue of the Lancet on public health in the U. S., more information on the special issue at the end of this podcast, they discuss the relationship between child cash benefits and health. With particular attention paid to studies of the large scale implementation of government programs in high income countries that are peers of the United States.

Hello, Luke. Hello, Mona. Welcome to the podcast, and thanks for joining us today. The U. S. is typically seen as the wealthiest country in the world, but people can often be shocked by learning that the U. S. has high levels of poverty and lower life expectancy than in many other countries. So can you tell us a bit about the state of poverty, including child poverty in the U.

S., and how it is typically defined? 

Luke: When we are measuring poverty in the United States and worldwide. Uh, we have a couple of different ways to do it. Uh, we have measures that try to say there are certain things that every family needs, like food and housing and transportation to get to a job, and it sets up a minimum dollar amount that would be required to, uh, meet those essential needs.

And then it says if families are below that line, they are in poverty, and if they're above it, they're not. So it is a, it's sort of a rough type of proxy, um, but most people in the United States think that, um, the, uh, poverty thresholds are too low, right? So if you imagine what you think in the United States it would take to, um, to survive, to meet your basic needs, uh, imagine what that number it is in, in the United States, it's something along the lines of, uh, 26, 000 for a family of three, maybe 30, 000 for a family of four.

And, uh, that doesn't, uh, account for a lot, right? And so what we see in the United States is actually a lot of families who are well above that line who are still really struggling. In Europe, uh, they tend to use a relative measure. And they say that if people get too far below, sort of, the typical income, uh, that they're in poverty.

And, and so that really starts from a logic that says, in any society, if you're, if you're too far below where everybody else is, you can't do the things that's required to be a part of that society. And so, that is sort of another way that we think about, uh, what this, what this threshold is. Um, none of these are sort of perfect and there's arguments for and against, but we see over and over again that, Uh, these markers of poverty are associated with material hardship, that people can't meet their needs, obviously, that they're associated with all sorts of, uh, impacts for children who are growing up.

And so, you know, there's just, uh, huge amounts of evidence that if we can reduce, especially child poverty, we can, uh, Improves so many of these other types of outcomes that we care so much about, and, uh, we can have positive impacts on development, we can have positive impacts on health, so we really think of it as like a root cause.

Jessamy: That's a brilliant answer, and I guess that's kind of related to, you know, progress. But I just wanted you to really lay out, what are the figures in the US? How many children are deemed in poverty? 

Luke: So right now, we're at about 13. 7 percent of, of, of Children who are under the poverty threshold as we, we define it.

Um, and so I have to get the exact number of Children that that's impacted. If you give me one second. 

Mona: Millions. Millions and millions of children. Millions is what we're talking about. In the richest country in the history of the world has millions and millions of children in poverty. 

Jessamy: And in terms of what we're talking about and whether we've seen progress in the last 20 years, obviously how you're measuring it makes a huge difference.

Like if you're going to change how you measure it, then you might not be seeing whether policies are making a difference or not. But Overall, over the last 20 years, have we made progress on that number? Or are we stalled on that, that number? 

Luke: Yeah, according to the poverty measure that is most prominent among scholars and the Census Bureau, uh, we were stalled out, uh, for about two decades.

And we were just sort of sitting right about at that level and it improved a little bit. worse during the last big recession. But then a pretty incredible thing happened in 2021. Uh, we launched a series of programs, uh, to really combat the pandemic, uh, programs, uh, That expanded unemployment insurance that weren't, uh, available to a lot of sort of low skilled workers, uh, workers in the gig economy or the service economy, the economic impact payments, and then most importantly, the expanded child tax credit.

That's a program that put us more in line with our European counterparts are, you know, higher income peers all across the world that said raising kids is expensive. And one very simple way that we're going to help families is by providing. $250 per child, um, 300, uh, per month per child if you're a young child.

And when we put all of those programs into place, we saw a dramatic decline in child poverty. Um, millions of children, uh, cut child poverty more than half. And we saw all these positive improvements, um, as a part of that. And then all of those programs were allowed to lapse and we went right back to where we were before 

Jessamy: on the, on the very quick impact of these policies.

It feels very rare to see such a sudden impact on something like child poverty in such a short time. I struggle to think of other health policies and other, where you get, you know, that, we're only talking 2021 and you're saying, we had a dramatic increase and then there's lapsed and we've seen the difference.

I mean, that seems really staggering to me. 

Luke: It's quite staggering. I think people don't understand how dramatic it was and it wasn't just in the poverty levels. We saw improvements in food insecurity. So the number of families with children saying they were food insecure fell to a historic low in that year as well.

Lowest we'd seen in more than two decades of keeping numbers. Credit scores actually improved to the highest for families that they had ever been at the end of that year. Then all of those programs are allowed to expire you and you immediately see things going in the wrong direction. Again, it's, it's quite striking.

Miriam: And Luke, I know you were, uh, quite central in helping to make some of this happen. What do you think it was that really helped enable this, um, tax credit to, um, you know, take place and, and occur in the US when it had not before? 

Luke: Well, uh, there have been incredible champions in Congress, uh, for a long time.

Rosa DeLauro in the House, uh, the name just one, uh, who had really been talking about this for a while. And I and many colleagues, you know, as you mentioned, wrote a paper back in Uh, started it back in 2016 that built on the ideas of many and, and really sort of laid out, um, the framework of 250 per child, 300 per young child.

Um, but I do remember when that paper was first, uh, presented, people said, this is pie in the sky. It could never happen here. But then people's minds sort of slowly started to change, and more and more, um, members of Congress signed on to it, and I, I think there was, there, there was a change both in our understanding of what the, the root challenges of poverty were, uh, at least among Democrats in the United States, uh, but also, you know, the, these policies, uh, Mitt Romney on the, on the other side of the aisle had a proposal that, um, Looks sort of strikingly similar.

They're important differences, but, um, more commonalities, huh? And then the pandemic happened. And for a brief moment in time, uh, we really thought about these issues in the United States differently. And, um, some of that, you know, as I mentioned, actually was a, was bipartisan. So the economic impact payments, the expanded unemployment insurance.

And, uh, and it put together this framework. I think it sort of sped up all of that sort of, you know, snail's pace change that have been happening before. Um, and then, uh, uh, presidential candidate, uh, Joe Biden, uh, was looking, I think, for something to do for families with children who are particularly hard to hit by the pandemic.

And, uh, he found this proposal, you know, where champions in Congress have been working on for a long time. So I think it's one of those examples of policy change where. Things are glacially slow for for years and years and then sort of hit hyperspeed at a moment 

Miriam: It's an incredible story and you know, dr.

Dr. Mona. I know that you're a pediatrician in Flint, Michigan, which is One of the, um, you know, poorest cities in the nation, um, with many families, um, unfortunately living in poverty. And you know, I wonder for you on the ground, um, these are your, these are your patients. Um, these are the families that you're seeing every day.

Um, what did, what 

Mona: did you find? Yeah, thank you for that question, Mariam. So, you know, as a pediatrician, I have, um, I have longed, like, for the ability to prescribe away poverty. You know, when my, uh, kids come into the clinic, when I have a little baby in my arms, Um, it is maddening. I feel like my hands are tied when I cannot do anything about the pathogen of poverty.

Uh, when, you know, we clearly know the science of what happens when babies are born into and grow up in environments of deprivation. Um, we know it's especially toxic, um, when they're young, when it's chronic and when it's concentrated. Um, and those are my babies in Flint. Those are the kids I care for.

Like you said, it's the, um, it's the poorest city in the state of Michigan, but it actually has the highest child poverty rate in the nation. Um, I think about last year it was 69%. And we also know that the younger the family is, the higher rate of child poverty. Um, so when the expanded child tax credit happened and it lifted millions of children out of poverty, um, we saw that in our patients.

We saw stress relief. We saw that ability to make appointments. Um, you know, we saw, um, you know, we, we saw families better able to care for their children, which is all they want to do. Every family wants to be able to care for their children. Um, and then when that was not renewed, um, it was, it was maddening because we know that poverty is a policy choice.

We know that we can fix this. And that expanded child tax credit was a proof point. It proved that we can't be like pure nations. We can't do these things that were once told. you know, that were impossible and not to do. Um, so I think that gave us a lot of hope, um, and a lot of kind of, um, you know, ability to kind of move forward because of that.

Jessamy: From an outsider's point of view, you keep saying like it was allowed to lapse. What does that mean? How can you allow something like this to just lapse? You know, you've got a government, you've got a political system, why don't they just say, oh, this is working, here's the evidence, let's go. Let's keep it going.

Luke: Yeah. I mean, the, the best day of my professional life was when those payments started to go out to families and we could see all the evidence, um, of it working. And then the worst day was when it became clear that they weren't going to extend that. And it got, um, sort of sucked up into debates, you know, as I mentioned, age old debates in this country.

So as I mentioned, um, We had a very different view on how to tackle child poverty during this time. And so we've already covered, we saw this dramatic drop and we saw kids doing better. But then as we started to come out of the pandemic, uh, these questions of like, um, why aren't people working is, uh, it comes up again.

And, and interestingly, the, the evidence is quite strong. Actually, we regained jobs and people went back into the labor force. It took a while, but. It was like the best recovery of the labor force that we've had after a recession ever, right? It actually, like, really, really worked. Um, and, uh, and so the, the research also on the expanded child tax credit in particular doesn't show really any anti labor market impacts, but it is a really strong narrative, right?

It's something that is just, uh, in the ether at any time. You know, employers are, like, searching for work, even though A lot of that challenge is actually demographic challenges that, um, we have an aging of the population. So we have fewer young people to do, you know, low paid service sector jobs right now.

Um, and then, uh, it was a question about costs too. And, uh, And are we willing to pay for this dramatic improvement? Uh, and, and it came one vote short. So with, with one more vote, it would have passed. It would have been extended. 

Jessamy: Because, you know, externally from outside of the U S we hear a lot about Bidenomics, uh, you know, about this sort of huge investment that's gone on in the U S and, and so.

This seems like something where there's, you know, there's a clear evidence base. There's a clear impact. Why wouldn't you use your political capital to say, let's put, you know, we've got all this money sloshing around, essentially. Let's put it in this direction. 

Luke: Yeah, well, I think, um, those, those partisan divides really came back up again.

Uh, After the after we started to come out of the pandemic. And so even though members of the other party had had proposals that looked, you know, somewhat similar, there was no chance that they were gonna, I think, come to a place where the president got a big win on this in the long term, there were some questions about inflation, too.

And again, I think those got pinned on these programs when the story about inflation was far more complicated than that. And you had supply chain issues. And, and all sorts of things. And the child tax credit is actually designed to have the least amount of inflationary impact, um, But, um, a few years ago, as I mentioned, when we were when I was first talking about this, um, there were no votes for it.

So it was a, it was a terrible moment when it wasn't extended. And just as you say, the evidence was so clear, um, that it worked. Uh, but on the other hand, um, Uh, there is a future where this does become permanent policy in the United States, and that's what RxKids is about, that we've been, we've been doing, and it's about keeping programs like this in the public imagination in the United States about a different path that really is possible, that we proved, uh, works.

Miriam: Why don't you tell us a bit about RX Kids now, uh, Mona, it would be interesting, uh, to hear from your perspective, uh, based in Flint, uh, what, what the idea behind it is and, um, what, what you see happening on the 

Mona: ground. Absolutely. So, you know, really kind of based on the success of the expanded child tax credit, this once again, proof that we don't have to shrug our shoulders when it comes to child poverty.

Um, we, uh, developed something that, um, was initially impossible. So the first couple of grants that we wrote for our kids, the comments were like, This is a great idea, but this is not feasible. You can't do this. Um, and I think that also gave us kind of further impetus. Like we, we, we can eliminate poverty.

We, we can do something at a scale that hasn't been done before. Um, so we call RX Kids a prescription for health, hope, and opportunity. Uh, it is the nation's first universal, uh, citywide, uh, maternal and infant cash prescription program. Um, so RX Kids kind of really, once again, built on the global evidence, built on the domestic evidence, especially from that expanded child tax credit, is trying to eliminate poverty, especially for moms and babies.

Uh, the maternal infant period is actually when families are the poorest in the United States. There's a perfect storm, income drops towards the end of pregnancy, babies are expensive, they need stuff. We don't have good paid parental leave policies in the United States. Uh, so the nadir of poverty is right at childbirth, which is really kind of maddening as a pediatrician because that's a really important time when it comes to neurodevelopment.

So RxKids is laser focused on moms and babies, the poorest time, once again, in, in the life course, but also this really, really critical neurodevelopmental period. We know that what happens in this window shapes the entire life course. Um, so, uh, RxKids launched in Flint in January of 2024. Um, and, um, It's for everybody.

It's for every single pregnant person and every, every baby. And that design, the universality, um, really was important to us. It made the administration really kind of easy, less burden. We're not figuring out who's in and who's out. Um, but also importantly, like, Um, Child Cash Transfers in other countries.

Um, it conveys a really different message that this is how we're supposed to care for each other. That, that raising a child is expensive, um, that, you know, there's a village, a society walking alongside you. It's all about reimagining that social contract. Uh, it also is about dignity. It's not about shame or stigma, like you're not making it so, uh, so, you know, you, you need help.

Uh, this is for everybody. Um, and then the cash prescriptions are unconditional, which is also based on global evidence, um, and that conveys trust, like we trust you. This is not another paternalistic program where we're telling you what to do. Uh, you know, you know how to make ends meet more than anybody else does.

Uh, you know, families don't need advice that who are in poverty, they need the ability to get themselves out of poverty. Um, so we launched in January, it's been amazingly successful. We've already prescribed over 4 million in cash to over 1, 000 families. Um, and we're absolutely seeing, um, decreases in hardship, uh, especially when it comes to housing stability.

We've had no evictions, uh, so far in our families, uh, based on a recent, uh, survey that we did. Uh, better food satisfaction, improved diaper hardship, and diapers are a big expense during this time, which is not covered by any other program. Um, um, And also, we're already seeing improvements in maternal mental health, less depression, less anxiety.

Um, and we took a sneak peek at vital records, which are kind of state administrative data that has maternal infant health outcomes. And as expected, seeing, um, great kind of health measures, improved prenatal care, more adequate prenatal care, and even impacts on birth weight and prematurity. So this is all as expected, uh, because as my colleague over here, Professor Schaefer says, this is the evidence based policy of evidence based policies, um, and we're already seeing those wonderful impacts.

Um, and we, we can't wait to kind of share these results, uh, and, and share this program with other communities. That 

Miriam: sounds really terrific. Um, but of course, we're, uh, just a few. Weeks out from, from the U S election. Uh, the elephant in the room right now, um, the world is, is watching, uh, what will happen here in the United States.

And, um, well, RX kids is, is. It's funded for a while and you'll, you'll have the results of that regardless, uh, of, of, uh, the election results. Maybe we can just discuss a little bit about what you think is, is at stake now. I mean, what are you hearing from the Harris administration, uh, Harris pre administration, uh, and, and, uh, from the Trump camp on how they might approach child poverty, uh, depending on who's, who becomes president.

Mona: I'll start. So I think the most exciting thing about our work is that it has really captured the nation's attention. Uh, so other, you know, people all over want to do something like RxKids. It's, once again, laser focused, it's time limited, it's relatively low cost, uh, with this potential for a tremendous return on investment.

Um, so, uh, we've heard that the Harris campaign was also sitting around and looking for good ideas. Uh, and as aware, was aware of our kids and included our newborn benefit in, um, her national policy proposal. So right now the Harris campaign includes a 6, 000 newborn benefit, uh, as part of her expanded child tax credit plan.

Um, and that is absolutely kind of because of our work that's already been able to inform national policy. Um, and I think something that Luke and I have been really kind of, uh, focused on is making sure that this is not a Democratic policy or a Republican policy. This is about babies. And everybody, Republicans, Democrats, everybody should be supporting babies.

Um, so we're expanding the program to the northern part of Michigan, the upper peninsula of Michigan, which is a very, it's a more conservative area, demographically, racially, politically different. And we have a Republican Senator champion up in that area who wrote an opinion piece saying why he is so excited about this program, too.

Uh, so, you know, we, we see the elimination of child poverty as something that everyone, no matter your party affiliation, should embrace and something that is absolutely at top of mind whoever is in the White House starting in January. 

Luke: That's exactly right. I think there's a path for our kids to continue to grow and expand, uh, no matter what happens in the election.

And, uh, so we're prepared to, uh, continue this work. Um, whoever, whoever's in charge in Washington. And as, as Mona mentioned, there's just so much interest from other communities. And we're hearing from states all over the country, stakeholders and, and states like, uh, Mississippi, just talk to someone. I'm not, um, Not that long ago in Arkansas, North Carolina, Ohio, Indiana, Oregon, just a wide range.

And so I think that's sort of a path that this can continue to grow is a path of state action because I think focusing on this, um, critical first year of life that we know has such consequences for, um, Lifelong development is something that can, can garner more appeal across the aisle. It's 

Miriam: really important because, um, you know, and you mentioned Mississippi, um, which has some of, unfortunately, the poorest indicators, uh, in the country, uh, for, for health and, uh, for education.

So, uh, the, the extent to which, um, you know, child poverty varies across The country, um, you know, it sounds like it can, what you're trying to do will still really be able to benefit, um, no matter where you are. And as you said, no matter what the next administration, um, may, may be thinking about. 

Luke: Yeah. One thing we haven't mentioned yet is that ArtsKids is funded in part through a block grant called Temporary Assistance for Needy Families.

And that was a block grant that was created as part of the 1996 welfare law. Um, that we thought was creating a workforce time limited welfare program that but really what I did was create incredibly flexible funding stream that states can use, quite frankly, to prop up their their budgets. And so. What we were able to do is create a pathway to support our ex kids with TANF dollars through a very arcane provision called non recurrent short term benefits that allows you to intervene during an acute economic crisis.

Um, and we define childbirth as that acute economic crisis. And if you look at the evidence, it's incredibly clear that it is, right? As Mona mentioned, it's the time when families are poorest and earnings go down and expenses go up. And so what that does is create a pathway that any state, all states have these TANF dollars and, um, many, uh, policy makers from Paul Ryan to Barack Obama have come to the conclusion that states don't use these dollars as they were intended.

Um, and, uh, that, that they're really using them to sort of often prop up the economy. Uh, spending and and other things. And so it creates a sort of a sustainable, um, funding stream that could be used by different states. It doesn't require philanthropy or even new money to sort of appear out of nowhere.

And so that's why we think. We could see it expand, uh, first across Michigan and then to a set of other states rather than requiring, um, necessarily requiring Washington to act at the front. 

Miriam: I really just have one, uh, one other question going back to, uh, something that we didn't, we didn't cover earlier, uh, which is, you know, if we look at child, um, you know, cash transfers, um, across the globe, what, what do we see?

Can you just tell us a little bit, uh, about that? about that, um, you know, how many countries, uh, have, uh, used child cash transfers and what does the evidence say, um, and if, if, if that's been helpful here in the U. S.? 

Luke: Well, this is, yeah, where, um, the, the perspective changes so much of, um, this isn't sort of a newfangled policy.

It is something that's used in, uh, more than 140 countries worldwide and the programs, uh, can take different forms. Uh, but that's the number of countries that have some sort of large scale government funded child cash transfer program. 

Mona: Which is over 70 percent of the countries in the world have some sort of child cash transfer.

That's amazing. 

Luke: So, uh, we see consistently evidence about, uh, improved, uh, uh, young child mortality, especially in, uh, lower income countries. Uh, we see across the board, um, huge reductions in child poverty, like, in higher income countries. Nations. It's one of the defining things that reduces child poverty.

Um, and so UNICEF has sort of highlighted it is like the backbone policy to a broader set of support for child well being investments and kiddos. We see, you know, families buying books and things to nurture their kids. Um, just really sort of a, a large set of impacts and, and, and some of the evidence that we build on in RxKids is the prenatal benefit too, that, uh, we can see improvements in birth weights and also, um, infant health and maternal health right from the start.

Miriam: Well, thank you so much. And I'd like to, to mention that, you know, all this work, uh, that, that you've been doing and the landscape of the, the, the policies around this. Are going to be, um, featured in, uh, a health policy paper, um, in an upcoming US special issue in The Lancet in early December. So, uh, I hope that that folks will come in and read more about it and will be very interested to hear how RX Kids goes along.

And I hope you'll come back and, and share it with us, um, again in the future. So, I wanna thank you so much for all your, for all your time today. Thank you. 

Luke: It was our pleasure.

Miriam: If our listeners would like to learn more about protecting the health of children with universal child cash benefits, you can read the health policy paper by the same name in an upcoming important special issue of the Lancet. And why are we publishing this special issue? It is to underscore the importance of this election cycle to the future of the public health of the nation and to the U.

S. 's standing in global health. We as the Lancet thought it very important to dedicate a special issue on this subject to really serve as a presidential briefing book on many of the most important health priorities to inform the next administration. This special issue will be published on December 7th, 2024, and will feature important comments from the National Institutes of Health, the Centers for Disease Control and Prevention, The Bureau of Global Health Security and Diplomacy and others.

The National Academy of Medicine's President will also discuss important policy directions for the U. S. And the Institute of Health Metrics and Evaluation will show us where the U. S. is in regard to health inequities, life expectancy, and other important indicators in original research articles. You do not want to miss reading this issue.

So that's all from us here today. Thanks so much for listening to this episode of The Lancet Voice, and we'll see you again next time.