The Best Approach to Social Determinants No One Talks About

I learned a few lessons when I was what then was colloquially referred to as a “welfare commissioner,” a term now out of use. One of them was that the main thing most low-income people needed was, well, more income. While that may seem oxymoronic, it’s not. Because what we mostly provide to lift them out of poverty isn’t more income, it’s services—in the language of the health care field—to address the social determinants of health.

At that time, there was plenty of violence and there were drug problems and homelessness on the streets of Camden and Newark, and in the hardest hit part of New Jersey, which was tiny Cumberland County in the southwest corner of the state, abandoned by Corning Glass and an oyster industry that had died off. But what I mostly found there were very low-income people, and immigrants, working hard at jobs that, to use a phrase I believe was first coined by poverty expert David Ellwood, “did not pay.” Many worked at two such jobs and sometimes three. (We need to “make work pay” was Ellwood’s refrain.) Most had the same aspirations as any American, and even higher aspirations for their kids, even as they had to cope with the often-abject circumstances around them.

It’s an ancient debate in the social sciences—whether the problems associated with poverty are more “cultural” (products of a “subculture of poverty”) or “situational” (a rational response to circumstances), or some combination of the two. But the health care field has not generally been a participant in the great debates about poverty, focusing much more on the impact of social determinants on health outcomes and very little on income and jobs strategies, which live outside of health care.

Against this backdrop, there are a smattering of programs across the country that take a different approach to poverty and its many effects. They have not received much attention, and they may want it that way. They are small scale, and it’s too early to draw any firm conclusions about them. But early results are promising, and they have a lot going for them.

“They” are the guaranteed income (GI) projects, which have sprung up around the country. Operating in at least 10 cities, each project provides low-income residents payments of between $375 and $1,000 a month, sometimes for special groups such as new mothers or single parents. Most are pilot projects serving several hundred families. Notably, a few have been organized as randomized trials.

One program that has recently been rigorously evaluated is in Cambridge, MA, where I lived for many years. The Cambridge program is a randomized trial called RISE, which stands for “Recurring Income for Success and Economic Empowerment.” It was launched by Mayor Sumbul Sidiqui and the Cambridge Community Foundation and evaluated by researchers at the Center for Guaranteed Income Research at the University of Pennsylvania.

In RISE, 130 low-income family caregivers earning an average of $20,246 a year were assigned to a “treatment” group receiving an additional $500 a month (their GI payment) and another 130 to a “control” group earning a similar amount who received no supplemental income. The average income for single parents with kids in Cambridge is $130,000, underscoring the income inequality in the area.

With a $500 monthly supplement, the experimental group receiving the additional income had more stable incomes, was better able to cover housing, utility costs, and emergencies and had greater food security. They could spend more time parenting and, the study found, more time with their kids meant their kids did better at school. It’s hard to believe that these impacts would not in some way also impact health. However, it might take years of sustained increases in income for those effects to be seen, and the pilot projects around the country haven’t been designed to capture that. Some GI projects have documented reductions in stress and improvements in mental health as improved circumstances have reduced chaos in the homes and repeated financial crises.

Critics of GI strategies hypothesize that they will create a disincentive to work. They did not, but they also do not remove other structural barriers to low-income parents working, such as the lack of affordable childcare. (Rare to non-existent is the policy that solves every socio-economic problem all at once.) The findings on work incentives are central to the debate about GI policy and I cite the researcher’s conclusions verbatim here:

“Throughout the duration of the study, the treatment group consistently reported higher full-time employment on average compared to the control group. The largest difference between the two groups was seen at 12 months, with 40% of the treatment group reporting full-time employment compared to 28% of the control group. While the percentage of stay-at-home caregivers was similar across control and treatment at Baseline (12% vs. 11%), by Endline, there was a higher proportion of stay-at-home caregivers in the control group compared to treatment (29% vs. 12%). Interview data shed light on the complex gendered familial and societal expectations that caregivers in the sample experienced. Further, the dual burden of unpaid care work and underpaid waged labor limited the power of GI and led to a common experience of forced vulnerability whereby participants were “forced” into dependent or toxic relationships out of necessity and survival rather than through choice. Although the GI created pathways of agency and opportunity for some, these pathways were often cut short by various environmental stressors and systemic constraints, highlighting the need for GI to be delivered in the context of a secure, broader, and equitable safety net that better supports caregivers. The lack of affordable childcare and flexibility for parents in the labor market consistently overlapped with experiences in the paid labor market.”

One huge advantage of GI programs is their “implementability” (a word I am making up that we should put into use). Unlike most of our “non-medical interventions” in health care, they do not present the issues Professor Martin Lipsky at MIT used to write about as the overlooked challenges of implementing programs that require a new “street-level bureaucracy” to deliver services. Examples include contracting with hundreds of community organizations; extensive outreach; cultural competency; and the many complexities of delivering services to at-risk, hard-to-reach populations. By contrast, GI programs give families cash, something that government is comparatively adept at doing. Government doesn’t always get benefits to every eligible person or family, but it does a better job of writing checks and delivering cash in various forms—and doing it at scale—than almost anything else. The Earned Income Tax Credit (possibly the most effective anti-poverty program we have ever had), the Child Tax Credit, and even the old AFDC cash assistance program are examples of that. Raising the minimum wage is another variation on the theme.

In addition to “implementability,” another big advantage is flexibility for families. The extra money can be used to buy better clothes for a job interview or to pay for a ride share to get to one instead of taking three buses; or to pay for diapers or formula, get a little bit ahead on the rent, get online, or buy food which is a little bit healthier; or maybe just to pay for a kid’s birthday party. The family knows, and the family decides.

There are limitations, of course. GI programs are not a comprehensive answer to poverty, the lack of affordable housing, or structural racism. Some could use the cash for undesirable purposes. Current pilot programs are locally financed, and their GI payments may be too small to make enough of a difference or may not be sustained for long enough. Ultimately, what matters most is better, higher paying jobs. And job training and supports, such as childcare, are essential to jobs policies.

The debate about service vs. income strategies is an old one. Both are needed. But both do not get equal attention, particularly in discussions of social determinants of health. If poverty is a core social determinant, income always matters. If you asked the low-income people in Camden or Newark or Cumberland County what would help them the most, I bet I know what they would say.

View all of Drew’s Beyond the Data columns.


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