The two big news events over the weekend were the Senate’s passage of the 1.9 trillion dollar stimulus bill by a vote of 50-49 and Oprah Winfrey’s interview with Megan and Harry. There may be more similarity in the two events than immediately meets the eye. Megan and Harry raised questions about inequality and a lack of security support for their biracial son, Archie. The stimulus package has substantial support for our nation’s children and is structured in a way to minimize the impact of race in determining the support offered to each child. Previous “welfare” programs to deliver relief to children in poverty have been discriminatory against many minority children. There is more to this story but let me digress:
One of the realities of the office practice of medicine is that what you see is a function of who has access to you. I have written a lot over the last thirteen years about the joy of practicing at the Harvard Community Health Plan during its heyday from the seventies until the early nineties. In retrospect, our panels of patients were skewed by some realities beyond my control. Most of the members we had during that period were employed. HCHP was offered by their employer usually along with other choices like Blue Cross, Aetna, or Tufts Health Plan. There were two sales involved for a person to become our patient. First to the employer. Second to the patient.
When a patient retired they often lost their access to us. It took me a while to notice that the path to us was a filter that meant that we saw few patients over 65. It was not until the late 80s and early 90s that we offered a “senior care” policy primarily to those who had been our patients through employer-provided coverage and had retired. There were other realities that I was slow to realize. First, we had a primarily white, suburban, middle-class population. A demographic study in the early 90s surprised me when it revealed that our patient population had a higher level of education and wealth than the average for the greater Boston area and even the western suburbs where wealth and education are common. We had a skewed population that was younger, wealthier, and better educated than the average for our locality. In essence, I was practicing in a very nice bubble where the impacts of the social determinants of health were minimized. One wonders what changes in society would yield a population that was as protected and comfortable as our patients were.
Dr.Ebert did have a great interest in the “urban poor.” When the practice began one of our offices was located in the Mission Hill area of Boston where there is public housing. Mission Hill is contiguous to the Brigham and Harvard Medical School. The federal government supported the care of the population as part of a pilot that aimed to demonstrate that access to a program of preventive health would make a difference in a low-income population. Even the Mission Hill population was primarily white but did include some Black and Latinx families. That project ran its course early in our history, and died by the time Ronald Reagan was elected with his dog whistle talk about “welfare queens.”
Without data to prove it, I can venture that most of my African American patients were either public employees who were employed by the state or one of the many municipalities that make up the Greater Boston economic region or were academics employed in one of the areas many institutions of higher learning or in a cultural program like public radio and television. Boston is sometimes described as forty towns searching for a city. The population of Boston is 685,000 (2019) and the Greater Boston economic area (Eastern Massachusetts) is almost 5 million. Our practice was skewed toward the middle-class employees of its many high-tech employers and the faculties of the numerous academic institutions of the area and away from the elderly and poor minorities. I had more PhDs than welfare recipients in my practice. That is not hyperbole. It was not until the late nineties and our period of near economic collapse that we began to grow our Medicare and Medicaid populations.
Since it was late in my career before we began to care for poorer populations, I am a relative “newbie” to concerns about the social determinants of health and I am reticent to “preach to any healthcare professional or provider organization” about their role in the care of the underserved. That said over the last twenty years I have come to the biased opinion that I and my organization were not atypical in our disregard for underserved populations and the enormous impact of poverty on the health of the poor and secondarily on the health of the nation.
Over the last decade of practice and clinical responsibility, first as chairman of our board and then as CEO, I tried to promote the growth of our Medicaid and Medicare practices, but I still did not have the full picture of the problem in focus. As we grew our Medicare practice it became easy to see what a burden poverty was for my elderly patients. I did not have a direct clinical understanding of the impact of poverty on children although I heard our pediatricians talk about what they saw. I had the good fortune to practice in Massachusetts which has a rather robust social service safety net and a good minimum wage. The minimum wage is $13.50 now and will be $15.00 in 2023. A report in 2017 stated that less than 10% of the population of Massachusetts lived on incomes below the poverty line and that it was one of only ten states that had poverty levels less than 11%.
When I moved to New Hampshire full time in 2014 I did not give any thought to its minimum wage or the effectiveness of its social services. I did not move here because it is 93% white and has a larger Asian population than the African American population. I also did not move here to continue any sort of clinical activity or to get involved in trying to improve my community. I came here for the lakes, the mountains, and the ability to enjoy the four seasons. I was retired. I thought that the “becoming” part of my life was over.
Not long after moving here a friend invited me to help in the delivery of wood to families in need who heated with wood. Before long I found myself involved in a non-profit that tried to make up for the totally inadequate social services of the state. You can’t expect much help if you are poor from a state that has “Live Free or Die” on its license plates. The organization I joined, Kearsarge Region Ecumenical Ministries, is a consortium of area churches. Our website says:
“… meeting the emergency needs of people in the Kearsarge/Sunapee region when other
services are unavailable.”
KREM can be of assistance when individuals or households have experienced …
- Unexpected loss of income
- Accidental Injury or serious illness
- Major crises which threaten children or families
- Other critical situations for which no other help is available
KREM will give up to $1500 a year to any one individual or family. We have been doing this for twenty years and in medical “jargon” we have many “frequent fliers.” The minimum wage in New Hampshire is $7.25, the federal minimum (this link is to a website that allows you to see the minimum wage in every state.) Both of our Senators ( Democrats who know the attitude in the state) voted against Bernie Sander’s amendment to add a $15.00 minimum wage to the COVID stimulus bill. I realize they have their eyes on challenges in the elections of 2022 and 2024, but their fear of voting for something that they will tell you that they support says a lot.
When someone asks for help from KREM we ask about their finances. Most of our clients earn far less than the cost of living index for our area suggests they would need. In 2004 Professor Amy Glasmeier of MIT created a living wage indicator for every county in the country. In my county, the living wage for a family of four with both adults working is $20.18 per hour per adult. With one working adult it is an astronomical $30.39 per hour. The biggest challenges here are the cost of housing and transportation. I cringe when I ask about their households and discover that there are several children and the annual income from all sources is less than $30,000.
The children of these families were getting help at school before COVID. There were also robust “backpack” programs at the local schools to feed these children on weekends. During the virtual schooling of the COVID pandemic, food is delivered during the week by the school bus drivers who are usually carrying the children to school. The pandemic has convinced me that there is nothing better than direct cash to support these children at risk. I was startled by the precipitous drop in requests for our help last year after the government distributed money to everyone, and evictions were prevented.
Over the last two years, we have started a non-sectarian organization, Kearsarge Neighborhood Partners, that helps individuals and families gain the financial skills they need to make good choices and to access all the benefits to which they are entitled. The mission of KNP is easy to say but difficult to accomplish:
Kearsarge Neighborhood Partners collaborates with individuals and organizations to create a support network which empowers people to achieve stability in their lives.
One of the motivations for this work is the knowledge that the impact of poverty on the children of these families will ensure the perpetuation of the same issues into the future. Childhood poverty in America is a disgrace that will ensure that the problems that face our children and grandchildren will be greater than the ones we have now. It is also true that unless we address poverty in general and childhood poverty in particular we will have no chance of ever having a healthy nation or coming anywhere close to the Triple Aim. Healthcare costs will continue to rise faster than the economy grows and in the end, we will all be worse off as Heather McGee describes in her book The Sum of Us: What Racism Costs Everyone And How We Can Prosper Together. New Hampshire may be 93% white but the poor white children here suffer from a history of abuse to the poor that arises from an incorrect racist concern that Black Americans abuse welfare. As Ms. McGee argues, we will deny all to be sure that we don’t give a nickel to a Black or undeserving “lazy” poor person.
The COVID relief bill that passed the Senate over the weekend will provide substantial ongoing relief for at least a year for poor children and their families. It would be wonderful if this relief could become permanent. It would be even more wonderful in the struggle to improve the social determinants of heath if there was a universal basic income (UBI). Andrew Yang ran for president on the promise of the UBI. Given our culture of self-reliance and fear of a government-managed welfare state, it is no surprise that a minority of Americans favor the concept of a UBI, but attitudes can change.
We have been led to believe that our society is composed of “makers and takers.” The reality is that the necessity of essential workers in our efforts to survive COVID 19 has revealed that many of our essential “makers” are being taken by the rest of us because they get low wages for work that we could not live without. Ronald Reagan told us many lies to make us feel good about the way we were self-serving. He gave us the vision of the “welfare queen” who produced babies to increase her welfare yield. He also falsely suggested that the really rich would pass through benefits to the really poor. Bill Clinton played along with his concept and upped the damage Reagan did by signing a poverty bill that was designed to end welfare as we have known it, and signing a crime bill that has lead to us having the largest prison population of any developed country. These policies dismantled much of our social safety net and sent many parents to jail while imposing work requirements and time limits for support on those in need. We live now with the legacy of these destructive ideas. It seems to be in our national psyche to be against the idea of adequately supporting the needs of a poor neighbor.
A few years ago I happened to hear of an interesting experiment to test the impact of UBI that was done in Canada in the seventies. Recently I heard again about “Canada’s forgotten universal basic income experiment.” The story is straightforward. The residents of an isolated town of 10,000 people in Western Canada were given a guaranteed minimum income. Contrary to what Ronald Regan was saying at the same time, the recipients did not quit work to watch TV, do drugs, or make extravagant purchases. They paid bills, put some money in savings, and even used the extra funds to start small businesses. The experiment continued for about four years until an economic downturn brought in a conservative government that killed the project. The data was put in boxes and stored away without analysis. A few years ago the data that was collected was exhumed and analyzed. It revealed that during the period of income support the mental health of the community improved, domestic violence decreased, small businesses were started, alcoholism did not increase, but savings did. More students graduated from high school. In general, the guaranteed margin of a few hundred dollars a month made a huge positive difference in many lives. The designers of the experiment did not plan for the most remarkable finding, when the support was withdrawn all the positive results vanished.
As mentioned above, I was surprised to observe that with the passage of each of the previous stimulus bills, the requests for financial help from our local non-profits decreased measurably. It seemed that when people got a little help they used it to pay their bills, and did not waste it on “luxuries.” I can only hope that it decreased their stress and supported their hopes and efforts to achieve financial stability.
You might have heard of the results of an American version of the Canadian experiment that was announced last week. A very young brash African American man ran for mayor of Stockton, California on a platform of income support. After he was elected many residents of Stockton were given $500 a month. I happened to drive through Stockton on my cross-country RV trip last fall. If you have never been there it is a West Coast version of the Bronx. I would imagine that life expectancies in its ZIP codes are below the national average. At the time I knew that the young mayor was in a political fight for his life. He eventually lost his bid for re-election in November. I did not know until this week that the preliminary results of his experiment are consistent with the Canadian experiment of the ‘70s. I would refer you to Meryl Kornfield’s report in the Washington Post last week entitled “A city gave people $500 a month, no strings attached, to fight poverty. It paid off, study says.”
I know from the non-profit work that we do in my town that $500 makes a big difference. As part of our work, we do a family financial analysis with a balance sheet that includes all sources of income and all expenses. Many of the families would be in a substantially different position with an additional $500 a month. In Stockton the study showed:
Residents of Stockton, Calif., who received $500 a month from a first-of-its-kind guaranteed-income program were more likely to find full-time jobs, be happy and stay healthy, according to a year-long study…
The study’s authors said they believe the payment recipients were better able to set goals and have their own agency to seek more stable employment. They were also less anxious and depressed, as well as less likely to feel fatigue or body pain associated with poor emotional health. Recipients, especially those in less-financially stable families, also stretched their resources to help feed their households and others.
My hope is that the forced experiment of the COVID stimulus bill will also demonstrate that monthly payments to families with children produce a measurable benefit to the health of the population. If that is true I hope that some permanent income support for families with children will eventual get the bipartisan support it needs to become a permanent benefit. Mitt Romney is currently pushing a plan that might achieve some of the same objectives. Is it possible that if we focused on the needs of children we could get bipartisan support for an effective approach to poverty that is impossible to obtain when we look at the issues from the perspective of their parents? If the results from Canada and Stockton are reliable predictors, and we do permanently increase the help that we provide the poor through some mechanism that could be negotiated while trying to improve the lives of children, we should see a further decrease in requests for help from non-profits and a measurable increase in health and mental health in our communities.
One of the biggest points that Heather McGee makes in her book, is that policies that help people are not “zero-sum” activities where what is done for one person must be paid for by others. Helping the poor is more like capital creation from investment. Many studies have shown huge returns on investment from programs that improve health and well-being for previously impoverished populations. It’s time to set our biases against the poor aside and do what is good for them and will be ultimately good for all of us. We could do away with the conversation about the social determinants of health by effectively addressing the problems and situations that perpetuate them. It’s a choice.
