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
Dr. King used his influence on President Kennedy and then on President Johnson after President Kennedy was assassinated to press the case for civil rights and for social reforms. Robert Caro, the biographer of LBJ, states that Johnson used the concept of completing Kennedy’s desire to improve the civil rights, health, and economic opportunities for America’s most challenged populations to make his case for being elected in 1964 after becoming president following Kennedy’s assassination. In a 2014 article the Washington Post called the 89th Congress which began its work with Johnson after the 1964 election the most socially productive Congressional session ever:
On May 22, 1964, in a University of Michigan commencement speech, President Lyndon B. Johnson formally launched the most ambitious set of social programs ever undertaken in the United States—surpassing even Franklin Roosevelt’s New Deal in its range and in its ambition to transform the country.
Most of the Great Society’s achievements came during the 89th Congress, which lasted from January 1965 to January 1967, and is considered by many to be the most productive legislative session in American history. Johnson prodded Congress to churn out nearly 200 new laws launching civil rights protections; Medicare and Medicaid; food stamps; urban renewal; the first broad federal investment in elementary and high school education; Head Start and college aid; an end to what was essentially a whites-only immigration policy; landmark consumer safety and environmental regulations; funding that gave voice to community action groups; and an all-out War on Poverty.
Johnson’s Great Society was an amazing vision that got off to a good start, but it was sidelined by the war in Vietnam. After Nixon and Regan the momentum was lost but some of its education and anti-poverty programs like food stamps, now called SNAP, Head Start, and fuel assistance programs for the poor have survived to this day. The interval history of the past fifty-plus years of our attempts to produce federal programs to address poverty is beautifully presented in a book, Jeff Madrick’s Invisible Americans: The Tragic Cost of Child Poverty, that was recently given to me by Joe Knowles, the CEO of the Institute for Health Metrics, who is a friend and “Interested Reader” whose innovative ideas I have showcased before. Joe’s smiling face is the header for this post.
The New York Times review of Invisible Americans: The Tragic Cost of Child Poverty presents the book as a great resource if we are really interested in reducing poverty in America and the impact of poverty on the health and well-being of children. You need to read this book if you think it is time to move from talking about poverty and its associated healthcare disparities to taking actions that will address the social determinants of health and improve the root cause problems that create the healthcare disparities that cause so much damage to current and future generations. The review begins:
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.”
Madrick’s book did not expand my vocabulary of acronyms for antipoverty programs, but it did something much more important. It reframed the whole discussion and put the entire process of trying to improve poverty into a historical perspective that goes a long way toward explaining why despite many efforts from people with good intentions we have been spinning our wheels while almost three generations have been born and progressed to adulthood since Dr. King pointed out that all we lacked in the effort to end poverty was the will to do it.
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.
Madrck 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.
Alissa Quart, the author of the review, is an authority on poverty in America in her own right. She is the executive director of the Economic Hardship Reporting Project. She is the author of six books, including Squeezed: Why Our Families Can’t Afford America, a book that I am adding to my “need to read” list. She finishes her review of Madrick’s book by bringing the subject back around to our failed dreams that inspired the Great Society more than a half-century ago.
The reason for his outrage is clear: Ending childhood destitution was a political centerpiece of the Great Society, yet now it is rarely mentioned, especially by politicians. If our leaders absorbed this book’s urgent call, perhaps they would discuss poverty — and act to ease it — once again.
I am encouraged that President Joe Biden’s American Jobs Act contains many programs that if passed would represent a return to some of the goals of the Great Society although it would be a political nonstarter for him to say that. He is running into enough resistance referring to them as “infrastructure.” The 1.9 trillion dollar American Rescue Act also contains experiments in antipoverty efforts that are consistent with Madrick’s concept that poor people and poor children would most benefit from cash. Unfortunately, the bill’s monthly cash supplement for children will end at year-end unless it is renewed. Madrick’s book is an argument for a form of income support targeted for children that is similar to the proposal for a universal basic income (UBI) that Andrew Yang presented during his campaign for the Democratic nomination for president. I discussed the benefit of such programs a few weeks ago in an article that showcased the UBI experiment in Stockton, California over the last few years, and the even more impressive study done in Canada in the ’70s in a post entitled “Considering Income Support As A Tool To Improve The Social Determinants of Health.”
At the time I wrote about Stockton or two weeks later when I wrote “To Discuss The Social Determinants of Health Is To Discuss Poverty” I did not know what Joe Knowles was planning to do. What I have learned in the interim is that Joe is putting Madrick’s suggestions into action. To invert and steal a phrase from Father Richard Rohr, he is “moving from contemplation to action.”
If you followed the link above to Joe’s bio you know that he is an entrepreneur. Like all good entrepreneurs, he needs to see if an idea will work. Joe recruited Jeff Madrick, and now me, to work with him and a talented team he has assembled and is funding with private philanthropy to test the benefit of giving new mothers living in poverty a monthly $400 dollar cash grant for three years. The idea, which has become a 501(c)3 named “Family Health Project,” is now a reality because it has its own website! And, it is already helping fifteen poor families. You must visit the site, but just in case you don’t I am cherry-picking several statements that I don’t want you to miss. The verbiage begins:
Believing that poverty is the fault of the poor settles us. Our responsibility to others can stay safely hidden as long as poverty is their fault and so dealing with it is by implication up to them. Poverty is not the fault of the poor. A sudden crisis in housing or health or home front, or lack of community resources, or the piling up of difficulties cause—and sustain—poverty.
Poverty happens to people, not the other way around.
The Family Health Project resonates with jeff Madrick’s ideas because he is on the Advisory Board of the new project. You can feel his influence in the introduction to the idea.
Family Health Project seeks to build on a simple idea, that providing reliable funds to those of us who need them most will have outsized benefits for those who receive them and for those around them. Family Health Project provides new mothers and their babies with reliable, unconditional funds monthly for three years.
We are amateurs in this field and so are deeply grateful for those who have chosen to participate with us. We will seek to expand our program, honing and improving it as we go. We hope to advance new and innovative thinking in the developing field of Universal Basic Income.
Here is the full description of this simple but elegant idea that is based on several studies that demonstrate that when given extra resources people in poverty respond by making good decisions that improve their condition and the lives of their children.
Almost 1 in 5 children in America live in families with incomes below the poverty line. Growing up in poverty increases exposure to factors that can significantly impair child brain development and lead to poor health outcomes.
Family Health Project has undertaken a simple, replicable program to help new mothers and their babies facing life without enough money.
Family Health Project will provide new mothers $400 each month for 36 months, through use of a debit card. Money will be provided without condition. Participants will be referred into the program by federally qualified community health centers. Funds will be managed and distributed through a corporate debit card partner. Participant onboarding and ongoing support services will be provided by an independent social services firm.
Family Health Project, an independent 501(c)3 organization, is funded solely by private philanthropists.
Family Health Project’s initial program launched this spring in collaboration with Lynn (MA) Community Health Center, with 15 families participating.
Family Health Project’s goal is to help prove the benefits that accrue to families from funds made available predictably and without condition over the first three years of a child’s life. With our initial pilot programs, we hope to demonstrate the scale-ability of this simple, reliable service delivery system.
How the program works
Modeled after the pathbreaking study, Baby’s First Years, the Family Health Project has 4 elements:
- Referrals: A Federally Qualified Health Center refers participants to us,
- Money transfer: $400 is sent to mothers via a debit card every month,
- Support: An independent social service firm provides ongoing support,
- Funding: The project is funded solely by gifts from individuals.
I am very excited about Family Health Project, and I feel quite honored that Joe has asked me to join the effort. I responded in a split second when Joe asked me if I would like to join its board. You may be sure that I will keep you up to date with our progress. Joe is already beginning to contact other federally qualified health centers with the plan to make the project more geographically and ethnically diverse.
I hope that you will visit the website where you can learn much more. If you are interested in knowing even more, please contact me.
