Poverty and health in the US
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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 Anomaly 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 policymakers to find new ways to prevent and alleviate poverty.

And Mona Hanna Atisha, who is the Associate Dean for Public Health and C.S. Mott Endowed Professor of Public Health at Michigan State University College of Human Medicine. 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 Hanna 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 discussed 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 on child poverty in the U.S., and how it is typically defined? When we are measuring poverty in the United States and worldwide,

We have a couple of different ways to do it. 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 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. But most people in the United States think that the poverty thresholds are too low. Right. So if you imagine what you think in the United States it would take to to survive, to meet your basic needs. Imagine what that number it is in the United States. It's something along the lines of twenty six thousand dollars for a family of three, maybe thirty thousand for a family of four.

And that doesn't 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, they tend to use a relative measure. And they say that if people get too far below

sort of the typical income that they're in poverty. And so that really starts from a logic that says in any society, 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 what this threshold is. None of these are sort of perfect and there's arguments for and against, but we see over and over again that 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 impacts for children who are growing up. And so, you know, there's just...

huge amounts of evidence that if we can reduce, especially child poverty, we can improve so many of these other types of outcomes that we care so much about. And 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. 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 U.S.? How many children are deemed in poverty?

So right now we're at about 13.7% of children who are under the poverty threshold as we define it. And so I would have to get the exact number of children that that's impacted if you give me one second. Millions. Millions and millions of children. Millions is what we're looking at. In the richest country in the history of the world has millions and millions of children in poverty.

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 number? Yeah, according to the poverty measure that is most prominent among scholars and the Census Bureau, we were stalled out for about two decades. And we were just sort of sitting right about at that level and it improved a little bit. It got worse during the last big recession.

But then a pretty incredible thing happened in 2021. We launched a series of programs to really combat the pandemic. Programs that expanded unemployment insurance that weren't available to a lot of sort of low-skilled workers, 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, our 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, $300 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. Millions of children cut child poverty more than half. And we saw all these positive improvements 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.

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 lapse and we've seen the difference. I mean, that seems really staggering to me.

It's quite staggering. I think people don't understand how dramatic it was. It wasn't just in the poverty levels. We saw improvements in food insecurity. 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.

And then all of those programs are allowed to expire and you immediately see things going in the wrong direction again. It's quite striking. And Luke, I know you were quite central in helping to make some of this happen. What do you think it was that really helped enable this tax credit to take place and occur in the U.S. when it had not before? Yeah.

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

But I do remember when that paper was first 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 members of Congress signed on to it. And I think there was a change both in our understanding of what the root challenges of poverty were, at least among Democrats in the United States.

But also, you know, these policies, Mitt Romney on the other side of the aisle had a proposal that looks sort of strikingly similar. They're important differences, but more commonalities. And then the pandemic happened. And for a brief moment in time, we really thought about these issues in the United States differently. And some of that, you know, as I mentioned, actually was bipartisan. So the economic impact payments, the expanded unemployment insurance,

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

And 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 years and years and then sort of hit hyperspeed at a moment.

It's an incredible story. And, you know, Dr. Mona, I know that you're a pediatrician in Flint, Michigan, which is one of the poorest cities in the nation with many families, unfortunately, living in poverty. And, you know, I wonder for you on the ground, these are your patients,

these are the families that you're seeing every day. What did you find? Yeah, thank you for that question, Miriam. So, you know, as a pediatrician, I have

I have longed like for the ability to prescribe away poverty. You know, when my kids come into the clinic, when I have a little baby in my arms, it is maddening. I feel like my hands are tied when I cannot do anything about the pathogen of poverty.

We clearly know the science of what happens when babies are born into and grow up in environments of deprivation. We know it's especially toxic when they're young, when it's chronic, and when it's concentrated. And those are my babies in Flint. Those are the kids I care for. Like you said, it's the poorest city in the state of Michigan, but it actually has the highest child poverty rate in the nation. I think last year it was 69%.

And we also know that the younger the family is, the higher rate of child poverty. So when the expanded child tax credit happened and it lifted millions of children out of poverty, we saw that in our patients. We saw stress relief. We saw that ability to make appointments. You know, we saw, you know, 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.

And then when that was not renewed, 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 peer nations. We can't do these things that were once told, you know, that were impossible and not to do. So I think that gave us a lot of hope and a lot of kind of, you know, ability to kind of move forward because of that.

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 keep it going.

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

We took 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, these questions of like, why aren't people working is it comes up again. And interestingly, the evidence is quite strong. Actually, we will regain 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.

And and so 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 in the ether in any time, you know, employers are like searching for work.

even though a lot of that challenge is actually demographic challenges, that we have an aging of the population. So we have fewer young people to do low-paid service sector jobs right now. And then it was a question about costs.

too. And are we willing to pay for this dramatic improvement? And it came one vote short. So with one more vote, it would have passed. It would have been extended. Because, you know, externally from outside of the U.S., we hear a lot about Bidenomics, you know, about this sort of huge investment that's gone on in the U.S. And so, you

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? Yeah, well, I think those partisan divides really came back up again 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 somewhat similar, there was no chance that they were going to, 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 all sorts of things. And the child tax credit is actually designed to have the least amount of inflationary impact.

But a few years ago, as I mentioned, when we were when I was first talking about this, 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 that it worked. But on the other hand, there is a future where this does become permanent policy in the United States. And that's what our kids is about, that we've been we've been doing in Flint. It's about keeping programs

programs like this in the public imagination in the United States about a different path that really is possible, that we proved works. Why don't you tell us a bit about RxKids now? Mona, it would be interesting to hear from your perspective, based in Flint, what the idea behind it is and what you see happening on the 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.

So we call our kids a prescription for health, hope and opportunity. It is the nation's first universal citywide maternal and infant cash prescription program.

So RxKids kind of really, once again, built on the global evidence, built on the domestic evidence, especially from the expanded child tax credit, is trying to eliminate poverty, especially for moms and babies. 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.

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 the life course, but also this really, really critical neurodevelopmental period. We know that what happens in this window shapes the entire life course. So RxKids launched in Flint in January of 2024.

and it's for everybody. It's for every single pregnant person and every baby. And that design, the universality, 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. But also importantly, like child cash transfers in other countries, it conveys a really different message that this is

how we're supposed to care for each other, that raising a child is expensive, that there's a village, a society walking alongside you. It's all about reimagining that social contract. It also is about dignity. It's not about shame or stigma, like you're not making it, so you need help. This is for everybody.

And then the cash prescriptions are unconditional, which is also based on global evidence. And that conveys trust, like we trust you. This is not another paternalistic program where we're telling you what to do. You know how to make ends meet more than anybody else does. Families don't need advice who are in poverty. They need the ability to get themselves out of poverty.

So we launched in January. It's been amazingly successful. We've already prescribed over $4 million in cash to over 1,000 families. And we're absolutely seeing decreases in hardship, especially when it comes to housing stability. We've had no evictions so far in our families.

based on a recent survey that we did, better food satisfaction, improved diaper hardship, and diapers are a big expense during this time, which is not covered by any other program.

And also, we're already seeing improvements in maternal mental health, less depression, less anxiety. And we took a sneak peek at vital records, which are kind of state-administrated data that has maternal infant health outcomes. And as expected, seeing 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, because as my colleague over here, Professor Schaefer, says, this is the evidence based policy of evidence based policies. And we're already seeing those wonderful impacts. And we can't wait to kind of share these results and share this program with other communities.

That sounds really terrific. But of course, we're just a few weeks out from the U.S. election. The elephant in the room right now, the world is watching what will happen here in the United States. And while RxKids is funded for a while, and you'll have the results of that regardless,

of the election results. Maybe we can just discuss a little bit about what you think is at stake now. I mean, what are you hearing from the Harris pre-administration and from the Trump camp on how they might approach child poverty, depending on who becomes president?

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

So we've heard that the Harris campaign was also sitting around and looking for good ideas and was aware of ARC's kids and included our newborn benefit in her national policy proposals.

So right now, the Harris campaign includes a six thousand dollar newborn benefit as part of her expanded child tax credit plan. And that is absolutely kind of because of our work that's already been able to inform national policy. And I think something that Luke and I have been really kind of focused on is making sure that this is not a Democratic policy or Republican policy. This is about babies.

And everybody, Republicans, Democrats, everybody should be supporting babies. 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.

So, you know, 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. That's exactly right. I think there's a path for our kids to continue to grow and expand no matter what happens in the election. And so we're prepared to continue this work, you know,

Whoever's in charge in Washington. And as Mona mentioned, there's just so much interest from other communities. And we're hearing from states all over the country, stakeholders and states like Mississippi just talked to someone 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 critical first year of life that we know has such consequences for lifelong development is something that can garner more appeal across the aisle.

It's really important because, you know, and you mentioned Mississippi, which has some of, unfortunately, the poorest indicators in the country for health and for education. So the extent to which, you know, child poverty varies across the country, you know, it sounds like it can

what you're trying to do will still really be able to benefit no matter where you are. And as you said, no matter what the next administration may be thinking about. One thing we haven't mentioned yet is that ARCS Kids 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.

that we thought was creating a work-first, time-limited welfare program. But really what it did was create an incredibly flexible funding stream that states can use, quite frankly, to prop up their budgets. And so what we were able to do was create a pathway to support our 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. 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 many policymakers from Paul Ryan to Barack Obama have come to the conclusion that states don't use these dollars as they were intended and that they're really using them to sort of often prop up policies.

of spending and other things. And so it creates sort of a sustainable 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 first across Michigan and then to a set of other states rather than requiring, necessarily requiring Washington to act at the front.

I really just have one other question going back to something that we didn't cover earlier, which is, you know, if we look at child, you know, cash transfers across the globe, what do we see? Can you just tell us a little bit about that? You know, how many countries have used child cash transfers and what does the evidence say?

And if that's been helpful here in the U.S. Well, this is, yeah, where the perspective changes so much. This isn't sort of a newfangled policy. It is something that's used in more than 140 countries worldwide. And the programs can take different forms.

But that's the number of countries that have some sort of large scale government funded child cash transfer program. Which is over 70% of the countries in the world have some sort of child cash. That's amazing.

So we see consistently evidence about improved young child mortality, especially in lower income countries. We see across the board huge reductions in child poverty. Like in higher income nations, it's one of the defining things that reduces child poverty. And so UNICEF has sort of highlighted it as like the backbone policy to a broader set of supports for child well-being.

investments in kiddos. We see, you know, families buying books and things to nurture their kids. Just really sort of a large set of impacts. And some of the evidence that we build on in RxKids is the prenatal benefit, too, that we can see improvements in birth weights and also in

infant health and maternal health right from the start. Well, thank you so much. And I'd like to mention that, you know, all this work that you've been doing and the landscape of the policies around this are going to be featured in a health policy paper in an upcoming U.S. special issue in The Lancet in early December.

So I hope that folks will come and read more about it. And we'll be very interested to hear how RX Kids goes along. And I hope you'll come back and share it with us again in the future. So I want to thank you so much for all your time today. Thank you. It was our pleasure. Thank you.

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.