19 November 2021
Dear Interested Readers,
Poverty, Children, and the Family Health Project of Joe Knowles
Last April in a piece entitled “Moving From Contemplation to Action” I began my introduction to of the Family Health Project which was the idea of Joe Knowles by writing:
If you ask yourself what are the origins of healthcare disparities your answer would probably be poor access to healthcare, poor access to healthy food, poor education in underserved communities, low wages, inadequate housing, lack of job opportunities, and exposures to environmental toxins which are more likely to be present in less desirable locations where housing is more affordable. The list is long and certainly includes other issues like less access to adequate transportation and a lack of adequate social services. If you think about those specific problems you realize that they are manifestations of two more fundamental issues: race and poverty. We are becoming more aware of the fact that the bundle of challenges that are associated with poverty create anxieties and emotional distress and have a significant impact on health and longevity of those in poverty. These days we talk about ZIP codes as indicators of health and longevity. The connection of human suffering to issues of race and poverty was not lost on Martin Luther King, Jr. When he was honored with the Nobel Prize in 1964 his speech reached beyond overcoming the challenge of centuries of racism to include the universal issue of poverty. He said:
“There is nothing new about poverty. What is new, however, is that we have the resources to get rid of it.”
Dr. King, Nobel Peace Prize address, 1964
Whether he was responding to his interactions with Dr. King, fulfilling the vision of the recently assassinated JFK, was motivated by his personal experience with poverty, or produced the idea as a self-serving political strategy, President Lyndon Baines Johnson shared Dr. King’s desire to eliminate poverty and his assessment that we had the resources to end poverty. During a speech given at Ohio State’s commencement in May 1964, he introduced his domestic agenda as “The Great Society.” The 89th congress which had huge Democratic majorities in both houses responded to LBJ’s challenge by creating many of the programs like Head Start, food stamps (now called SNAP), and winter fuel assistance which still remain as important components of our tattered and inadequate social services safety net. Unfortunately, the war in Vietnam undermined the meritorious Great Society efforts.
There is no question that the various ideas that are included in President Biden’s proposed expansion of support to our “human infrastructure,” The American Families Plan or his wider strategy to Build Back Better, constitute the most significant efforts in the past fifty years, and perhaps ever, to improve the lives of all Americans. The president’s proposals if passed would lift millions of Americans, especially children, into a future where they have a real opportunity for health and happiness as we turn poverty into a problem of the past like polio or smallpox.
In the April piece I referenced a book by Jeff Madrick entitled INVISIBLE AMERICANS: The Tragic Cost of Child Poverty that Joe Knowles had given me to read. The New York Times review of the book was written by Alissa Quart who is the executive director of the Economic Hardship Reporting Project, which in cooperation with The Nation produces the podcast with Ray Suarez, Going For Broke, which I have recently brought to your attention. In the review of Madrick’s book, Quart wrote:
It’s a paradox of American childhood poverty that experts routinely devise the most complex solutions for it — or in recent parlance “innovations” — most of which are elaborate, costly or otherwise impractical to implement.
Jeff Madrick is an exception to this rule. In his new book, “Invisible Americans: The Tragic Cost of Child Poverty,” he argues for a solution for children so simple that even a child could understand it: Give poor families money for their kids. In clear, spare prose, he lays out a proposal for something akin to a basic income guarantee for parents of children under 18. “Poor children have many requirements, but above all they need money,” he writes. He returns to this point repeatedly: “Child poverty is too punishing and harmful to wait years for results — especially when cash distributions can help today.”
I added my own comments about what I had learned from reading the book. I have now bolded a statement to which I will return later.
There is no question that persistent poverty is the root cause of our frustrations and inability to do much with the healthcare inequities and disparities that follow racism on the list of our national disgraces. Madrick gives a very lucid description of how our programs have helped some of those who live near the poverty line while they have simultaneously made life even worse for our poorest citizens and their families.
Madrick explains that one of the reasons we fail is that the “poverty line” is a political metric that by consensus is set much too low if our objective is to identify those who need help and could easily do much better if they had consistent assistance. By our standard there are 13 million children in poverty. If we were to apply the standards that define poverty in Europe we would have more than 21 million children who are impoverished. Madrick believes that even the Eurpoean standard fails to capture all of the children whose lives could be improved by more available cash for families that remain under financial stress. He presents a good case for the fact that at the root of our failure is the reality that many of us blame the poor for their own miserable state and do not see it as our personal responsibility, or the responsibility of the government to do anything about it. It is also a reality that by failing to effectively address poverty we incur huge national losses of human potential and incur other expenses in policing, incarcertion, and healthcare.
Before Joe Manchin and Krysten Sinema began their resistance and negotiations designed to reduce the extent (cost) of the investment that the president is urging us to make in our future, the president’s bill was designed to indefinitely extend the benefits for children and families that were present in the “American Rescue Plan Act” passed earlier this year. Some of the families that would benefit from a long-term extension of the benefits of the “rescue plan” were below the poverty line, and some suffer the challenges of poverty but are above the artificial “poverty line” that federal programs recognize. A White House Fact Sheet for the proposed “American Families Plan Act” written last April before it got the hatchet wielded by Manchin and Sinema described the rationale and intent of the president for giving impoverished and “working-poor” families more assistance. As Madrick’s book details, there is a wealth of data that confirms the lifelong damage experienced by children who are raised in poverty. There is also evidence that those life-long deficiencies can be diminished by relatively small amounts of money given to families in need.
Long before the president was elected Joe Knowles had become convinced that we had been studying the long-term negative effects of poverty on children for too long, and it was time for someone to act. All the discussions and insights in the world produce no improvement unless they lead to action. Joe decided to use his organizational skills, personal resources, and knowledge of public health policy to construct a privately financed pilot to test whether giving a small monthly direct cash grant for the first three years of the life of their babies of mothers living in poverty would lead to better outcomes for the children. In essence, Joe developed an experiment in universal basic income (UBI). A few weeks ago the Family Health Project published on its website the lessons learned over its first six months of work. Joe has given me permission to pass the report along to you. What follows is the report of the lessons learned during the first six months along with a few comments from me. If you would like to have a clean copy of the report that you could forward to others whom you think might be interested, you can access the entire report by clicking here.
Nearly six months into a three-year guaranteed basic income pilot to help first-time mothers get off on a strong foot, we’ve learned a few lessons about what it will take to go to scale.
Five and a half months ago on Mother’s Day 2021, we enrolled our first mom-to-be in the Family Health Project pilot. She was one of 15 young women in Lynn, Mass., living in poverty and about to have their first child. Each would receive $400 a month for three years to use as they needed.
The goal of the pilot program is twofold. First and foremost, we hope the $400 each month will help these young mothers invest in their baby’s early development at this critical juncture in their lives and lift them out of the harmful grip of poverty.
Second, we want to test this model in the most authentic way, by actually operating it, so we can perfect it, thereby taking it to scale and reaching thousands of young mothers at a diminishing cost per person. Scale is critical to public health efforts like these, but it is still far too rare.
To “go to scale” is an iterative, fail-fast process. The task is to figure out how to scale while you’re scaling. In fact, if something works well you can count on the fact that you’ve messed up but you just don’t know quite how yet.
In that vein, below are the lessons we’ve learned so far.
But first, the elements that, in theory, should make the Family Health Project scalable. Importantly, in each case, we did not hire or train new professionals. We have no overhead, no payroll; we have no offices. We rely on the expertise of others who do their job well.
The Elements of the Family Health Partnership That Make It Scalable
Element 1: The first critical element is the referral process because as Family Health Project founder Joe Knowles put it, “You can’t just put up a billboard and ask people who want money to contact you.” We use a referral source that, importantly, is found nationwide—a Federally Qualified Health Center (in this case, Lynn Community Health Center). FQHCs serve more than 30 million low-income patients and operate in every U.S. state—reach that will be critical to scaling. The referral is simple and adds only minutes to an already planned meeting with a caseworker during the woman’s third trimester of pregnancy.
[I am happy to add that Joe has informed me that the program will be soon available at the Whittier Street Health Center, also an FQHC, located in the Roxbury section of Boston.]
Element 2: A social service agency (in this case, Wellspring) to support the mothers in other aspects of their lives and to act as a human touchpoint for them. Wellspring has more than 40 years of experience as a hands-on, in-depth service provider. Wellspring caseworkers are also accustomed to working with an individual for longer periods of time, which in the case of our young mothers will be three years. That span gives Wellspring an opportunity to help the mothers get established in life, with a job or education or other supports.
Element 3: A scalable way to deliver the money, in this case via a debit card company that specializes in digital transactions without requiring Social Security numbers, which would otherwise prevent undocumented women from participating.
On paper at least, it should work.
Lesson 1: Referrals. If you don’t set up a system that randomizes the caseload, it won’t happen.
After 5 months, we had referrals for 15 women, our cap at the time. But rather than being a group of women from different backgrounds reflecting the diversity of greater Boston, or even Lynn, all 15 were from Central America and spoke only Spanish, and they all were in dire need.
It turns out that caseworkers will, by their nature, refer those with the most need first, and in this case, one of the two caseworkers worked extensively with Central Americans–thus the preponderance of Spanish speakers.
While it seems imperative to help those with the most need, more caseload diversity ensures those who need the most attention will get it if not everyone is having the same issues at the same time. The Spanish-speakers also required us to invest in translation technology, including texting and telephone programs. Wellspring has also stepped up their timeline for hiring a native Spanish speaker.
Solution: We are still determining how best to randomize the referrals, but one option is to refer those who show up for, say, the 9 a.m. and 3 p.m. appointments one day and the 11 a.m. and 2 p.m. the next.
Lesson 2: Face-to-face relationship-building is critical
For a variety of reasons, the young mothers’ first reaction to hearing we are giving them $400 a month is “are you for real?” They are wary of no strings promises, and because of this group’s immigration standing, they are doubly leery of “officials.”
“We built in a fair amount of in-person contact in the first few weeks,” said Dimond, in order to assuage doubts and build trust.
Wellspring staff also spend time explaining how the $400 a month income bump will affect any other government supports they are receiving. A rise in income can mean the loss of other programs like food stamps or housing vouchers. Family Health Project had managed to secure a special state waiver from such “benefits cliffs” in all programs except housing. Two women chose to not participate because they would lose their housing support.
[Elligibility requirements for assistance programs have been a huge barrier to accessing social service programs. Many people who could benefit from assistance are denied help based on the sense that they make too much when in reality they are impoverished. As I will discuss later our collective bias against the poor has been enhanced by the legacy of Ronald Reagan who warned us of “welfare queens” whom he alleged have great skill in having more babies to acquire more luxuries at the expense of the public. We are very careful not to “give” anyone too much help. As Joe feared, some mothers who could have benefited from the $400 a month did not accept the offering for fear of becoming ineligible for other benefits that were critical to their existence.]
Lesson 3: Don’t assume recipients are familiar with debit cards
Coaching and tight communication are essential in using the debit card. Wellspring spends considerable time explaining how to avoid bank fees, how to set up passwords (and what to do if you forget it), and even how to use an ATM. Some of the moms are quite young (the youngest is 16) and have never had an ATM card. About one-third needed hands-on coaching. The most unexpected lesson came from lost passwords. It’s a common thing, of course. Forget a password, try one too many times with a guess and get locked out, followed by a bank’s email alerting you to potential fraud. But for an undocumented woman from Central America, a big red “fraud” message from an official sends her underground. The team learned that delivering the debit card in person one month before the baby is born offers a chance to explain what to expect and walk through any hiccups face to face. The caseworkers also reassure the women that this is not a bank account in their name, that a Social Security Number is not required and everything remains anonymous.
Wellspring also learned that having access to the woman’s account allowed staff to trouble-shoot when problems arose. Rather than calling customer service, which can be overwhelming, the moms can call Wellspring for help. “Call us first,” is our first line of defense, Dimond said.
These are just the start of the lessons we’ll be learning from and adjusting as we go, all with the aim of helping increasingly more young mothers and their babies secure their futures. Stay tuned as we continue to learn and adapt.
I am very impressed by the intelligent design of this project, and even more impressed by the real-time problem solving that is generating continuous improvement of the project. I am most impressed by the concern, caring, courage, and commitment to alleviating needless suffering that Joe and his collaborators are demonstrating with this bold project. Joe has innovative freedoms that don’t exist in a federal program that is the product of compromises between those who want to see efforts to aid the poor succeed and those who are afraid that a new program will succeed and lead to more new efforts. With a few seconds of effort on the Internet, you can find many articles about the limited successes and the multitude of failures associated with the Great Society. My bias is that many of these articles arise in “right-leaning” organizations and think tanks where there are those who focus on the failures of previous efforts to help the poor in order to generate reasons to explain why it is futile to use federal resources to make an effort to eradicate poverty or ameliorate its harm.
Joe’s experience points out the universal principle that progress is a function of many failures. Failures and unexpected problems are as necessary to innovation as sunshine, adequate water, and fertile soil are to growing a bountiful crop. A problem identified is an opportunity for improvements that will lead to even more problems that will lead to more improvement. The greatest threat to this cycle of improvement is the naysayers who will use each identified problem as a reason to drop the effort entirely. We must use data like Joe is generating to effectively challenge their negativity.
By being privately funded Joe can develop a scalable program. Unfortunately, if the program is ever going to be more than a sip of water for a host of thirsty people, what Joe and his collaborators are learning must eventually be raised to a universal scale. The collection of ultimate barriers that prevent a successful transfer of the learnings of a progressive pilot to the level that can help all who are in need are well rooted in our history and culture and have been enhanced over the last several decades by the growing divisions in our society.
I am continuously thinking about why a country as wealthy as ours can’t respond to large problems like poverty, drug dependency, gun violence, inadequate housing, and global warming. There has been ongoing strife between those with capital and those in poverty within our society since colonial times. In the late nineteenth century, early twentieth century, around the great depression, and in the sixties there were brief periods of time when those who realized that ultimately we were all at risk if any of us were at risk held power. At each of these times some progress, much less than hoped for by progressives, was made. The efforts in those intermittent moments of opportunity abolished child labor, created the forty-hour workweek, improved education, created Social Security, launched Medicare and Medicaid, and did give us the little bit of a social safety net that does exist. Few programs of enduring social benefit were launched by politicians influenced by tax-averse business interests. Again, we are at one of those moments where great progress is required but marginal gains will be deemed to be all that compromise will allow.
There are several national biases that contribute to the difficulty to make improvements. First, as a nation beginning with many of the drafters of the Constitution who were the wealthy of their day, we don’t trust the federal government. Second, we are hesitant to use public resources to help anything other than businesses. Perhaps that is because “business” writ large has substantial control of our government through our electoral processes that are dependent on outside funding. This sad fact was made worse by the Supreme Court’s “Citizens United” decision of 2010. For example, because of his connection to, and personal investment in coal, perhaps Joe Manchin is more a representative of big energy than he is the advocate for improving the individual challenges of the poor in West Virginia.
In essence, we don’t trust the government. As Ronald Reagan famously said, “The nine most terrifying words in the English language are: I’m from the government and I’m here to help.” The back and forth oscillation of political control and the compromises necessary to get anything passed is further augmented by a culture that really believes that every individual with gumption can escape poverty on their own. We love the Horatio Alger myth and the concept of lifting oneself up by one’s own bootstraps. Again, the high priest of this attitude in recent times was Ronald Reagan, although Bill Clinton’s efforts to “end welfare as we have known it” was built on some of the same ideas. The sum of this attitude is that if a person is poor it is because of some personal defect. It’s their own fault. Another attitude that creates a current against which efforts to end poverty must swim is that given the chance the poor will cheat. That is the explanation for many of the barriers that the mothers that Joe’s Family Health Project seeks to help face each time they try to get help.
I was surprised this week to read an opinion piece in The New York Times that supports many of the biases I have expressed above as well as my desire to hold Ronald Reagan accountable for much of the misery the poor have experienced over the last forty years. The article entitled “The Shadow of Ronald Reagan Is Costing Us Dearly” was written by Claire Bond Potter, who is a professor of history at the New School for Social Research. She writes:
With Build Back Better, President Biden has attempted to revive a New Deal ethic that entwines human and physical infrastructure. No one likes taxes, but building a nation where Americans know that their families are safe and cared for is popular across party lines. It shouldn’t have been a hard sell.
But here we are. The reconciliation package has shrunk to about $2 trillion. And something else is gone: a chance to change the American narrative of what good government does. The legislation was once billed as a plan for sweeping once-in-a-generation social change, but aspects of it that warranted that hyperbole, like dental and vision coverage for Medicare recipients and free community college, have disappeared. Paid family and medical leave have been sharply reduced.
Other industrialized nations provide a far more robust safety net than the one we have and even the one Mr. Biden proposed. Yet Republicans and at least one Democrat insist that such social welfare spending endangers the nation’s fiscal and moral health.
How did we get to a point that doing less for Americans is a virtue, and comprehensive social welfare a privilege?
To answer her own question she goes back to January 20, 1981, the day Ronald Reagan was inaugurated. She writes:
In his inaugural speech, he [Reagan] linked government itself to national decline. The economic crisis of the 1970s, he declared, was “proportionate to the intervention and intrusion in our lives that result from unnecessary and excessive growth of government.” Social programs were wasteful. Worse, they lured families into dependence.
In other words: The government that helps families most helps them least. It was an idea that became an American ethic, with staying power through Republican and Democratic administrations alike. Attacks on social programs portrayed poverty as a moral failure and exploited racist stereotypes to mischaracterize social welfare as a magnet for criminal, failed and indolent Americans. The belief that successful families helped themselves remained an article of faith in both parties until the socialist Senator Bernie Sanders ran for president.
I will let you choose to read the bulk of her argument if you are so inclined. She does not exonerate Democrats. There has been a coalition across the aisle that explains much of the mess that we lump together as the social causes of disease. Joe Knowles and Joe Biden are right to begin the new war on poverty by focusing on the children in poverty. At the end of the piece Professor Potter writes:
Thus Reagan-era bromides are alive and well, even in the Democratic Party, and they are undermining good-faith efforts to help a besieged middle class, too. While Senator Joe Manchin has said that he is not against paid leave, some of his comments continue to perpetuate the myth that comprehensive social welfare programs are a national moral hazard. “I cannot accept our economy or basically our society,” Senator Manchin declared as he demanded more cuts in human infrastructure, “moving towards an entitlement mentality.”…
…what Mr. Biden wanted, and America required, won’t happen: a universal safety net that covers the needs of Americans as a right, not a privilege, and a revised tax structure that asks the wealthiest Americans to support the work force that made them rich…
The myths of American individualism planted and nurtured under Mr. Reagan continue to cost us dearly as a nation. “In this present crisis, government is not the solution to our problem; government is the problem,” he insisted in that first inaugural.
The time is long overdue to reverse that equation.
I am delighted that while we continue to struggle to overcome our collective biases that damage the poor everyday people like Joe Knowles are testing ideas and are pragmatically trying to learn new ways to improve the lives of poor children. Every child should be entitled to the opportunity of a healthy life even if we are going to continue to demand that the poor solve their own problems.
What Lies Ahead?
It has been a warm fall, but now we are headed indoors. COVID cases, hospitalizations, and deaths are on the rise in my state. We canceled our church services last Sunday because a staff member, though vaccinated, was quite ill and remains ill with COVID. The reports here are that the hospital resources are stretched and no relief is in sight as we face the holiday season with a desire to gather with family and friends.
I have received both a Phizer booster and a flu shot. I wear my mask when I am out and in contact with other people. My heart goes out to all of the caregivers who will need to work so hard and under difficult circumstances during the holidays. I do hope that your Thanksgiving Day will be safe and rewarding.
On a more positive note, I am delighted to report that my ability to walk is much improved and just in time because when the temp is in the mid-thirties I find it too cold to take a bike ride. There is a real wind chill factor when you are breezing down a steep hill. On Wednesday I was able to walk five miles using my brace for the first time since my fall last February!
I hate coming indoors and riding my Peloton, but I should be thankful for the option. When I do ride indoors I prefer the option of a “scenic ride” rather than following the lead of some manic instructor who is forty or fifty years younger than me and is playing music I don’t like. On a particularly cold and rainy day last weekend, I took a one-hour ride on my Peloton through the gorgeous Canadian Rockies while listening to Susan Werner’s music on Spotify. It was a good workout.
This week’s header is another screenshot that I lifted from the recent video published by my neighbor, Peter Bloch. As I mentioned last week, the video is appropriately titled, “Awaken the Lake.” There is an ethereal beauty to an early morning mist rising from the lake. I erred last week when I said the loons had left. We saw one at our end of the lake on Wednesday.
I have frequently described our lake and the peninsula that divides the lake that was created by a melting glacier over twelve thousand years ago. Peter’s drone photography proves that a picture can be worth a thousand words.
I hope that your Thanksgiving is safe and satisfying. Don’t forget to get some exercise before you overeat!
Be well,
Gene
