194: How evidence-based policies can help alleviate poverty and improve health equity
Poverty is a key driver of health disparities. But numerous policies have been shown to help alleviate poverty and improve health equity, according to Dr. Rita Hamad, associate professor of social and behavioral sciences at the Harvard T.H. Chan School of Public Health.
To address the problem, Hamad says policymakers need to look upstream and identify the root causes of health issues.
“And really recognizing that poverty is one of the major root causes of those issues, and that if we don't address that… those health issues are just going to keep arising and not getting any better,” she says.
On this episode of the Health Disparities podcast, Hamad speaks with Movement Is Life’s Dr. Charla Johnson about evidence-based policies for alleviating poverty — like the child tax credit, earned income tax credit — and explains how healthcare systems can get more involved in bolstering the social safety net.
Never miss an episode – be sure to subscribe to The Health Disparities podcast from Movement Is Life on Apple Podcasts, YouTube, or wherever you get your podcasts.
The transcript from today’s episode has been lightly edited for clarity.
Dr. Rita Hamad: Trying to understand that if we want to shift those health behaviors and improve health outcomes, we really need to look upstream. So, you know, we use that term to mean like, looking at the root causes of what those problems are, and really recognizing that poverty is one of the major root causes of those issues, and that if we don't address that, and if we sort of work on, like, you know, Band Aid solutions, addressing just the health issues. Those health issues are just going to keep arising and not getting any better.
Dr. Charla Johnson: You’re listening to the Health Disparities podcast – from Movement Is Life — being recorded live and in person at Movement is Life’s annual health equity summit.
Our theme this year is “Health Equity: Solutions from Healthcare Leaders.” I’m Charla Johnson, a member of the Board of Directors and Secretary for Movement is Life. I'm also a registered nurse. I am the director of clinical information systems and nursing informatics and certified in both orthopedics and in nursing informatics and happy to be here today. In today’s episode, we’re going to take a close look at evidence-based policies to alleviate poverty and achieve health equity. Our guest today is Dr. Rita Hamad — a social epidemiologist, family physician, and the director of the Social Policies for Health Equity Research Center at the Harvard School of Public Health. Dr. Hamad – Thanks for being here!
Hamad: Thanks so much for having me.
Johnson: Tell us a little bit about yourself, and how is it that you came to focus on poverty alleviation and your work on health equity?
Hamad: So I think the moment that really crystallized it for me was an internship I was doing right out of college. I happened to get very lucky and had an internship at the World Health Organization, actually in Geneva, and at that point, they were doing a lot of work on HIV AIDS, and I was sort of like a, you know, right out of college, didn't really know what I was going to do. What I was going to do with my life, but the more I learned as part of that internship about the struggles faced by people with with that chronic disease and other chronic diseases, it sort of really felt that a lot of the conditions that they were dealing with were rooted in their own experiences with poverty.
They were unable to, you know, really deal with their health issues because of the social and economic challenges they were dealing with. And I think at some point it just sort of clicked with me and resonated with my own childhood. So I, you know, arrived in the US as an immigrant when I was much younger, and I actually, you know, my family was on a lot of the social safety net programs that I now study, that we, you know, had food stamps, and I remember standing in line with my mom while she redeemed them at the grocery store. And that I saw in the, you know, stories about people with HIV that I was learning about the same struggles that I experienced as a kid, and I think that sort of drove me to want to study those issues. So then I, you know, soon after that internship, I ended up going to medical school to learn more about health and health equity, and then ended up getting a PhD in epidemiology to really understand the drivers of health equity with a focus on those social and economic drivers, and that sort of, you know, eventually led me down the path that I'm on today.
Johnson: Awesome. I know in one of our conversations earlier, you mentioned about kind of like a mentor or someone that you looked up to, and we had her as a speaker yesterday around the weathering and so I it's interesting in your your childhood experiences and all these connections have led you to a place of passion to be able to actually bring solutions in a big, broad way. So very interesting. Thank you. So you're a physician and a social epidemiologist and studying the impacts of social and economic policies on people's health. So what kinds of research questions are you focused on right now?
Hamad: Yeah, so a lot of my research questions are inspired by people like yesterday's speaker Arline Geronimus and others in the field of social epidemiology and social sciences, where people, for really decades, if not longer have recognized that, you know, economic issues like poverty are really closely tied to health equity. And as I, you know, proceeded through my training, I felt like I didn't just want to study those disparities. I wanted to study solutions to those disparities, and not just solutions sort of in like one on one clinical settings, but really these population level solutions that could address disparities at the population level to really have a more upstream impact on health. And so that's sort of what drove me to the research questions that I focus on now, which is trying to understand the impacts of the. These are poverty policies, ones that focus on increasing people's income, on improving their nutrition, improving housing, addressing school segregation, which we also know is a determinant of health inequities. And so my research is focused on understanding how those policies impact health and also places where they fall short. How can we be making these policies better? Who are they working for and not working for? What are sort of the implementation challenges to really make sure that the research is informing actual action by either policy makers or community members?
Johnson: Wonderful. So you talk about that actionable evidence to inform the policy making, and you kind of talked this morning around the sale to society framework so that pathway, that linkage, you know, of these policies to kind of reduce poverty and improve health equity, how, what kind of framework or kind of share those experiences that your team has?
Hamad: Yeah, so, you know, one thing that we try to focus on is not just looking at health inequities and sort of putting the blame on the person themselves for not behaving properly, for not, you know, exercising more and not eating the right things, and, you know, smoking or drinking or all of those things, we try to understand what are the root causes of those behaviors, and thinking about how a lot of times people are sort of trapped in situations where they really don't have a lot of flexibility in their decision making. Maybe they're not exercising right and eating right because they live in a low income neighborhood where there's no sidewalks and no green spaces or no grocery stores. They live in food deserts. Or, you know, they're stressed by their economic situations. And so, you know, we know that people who have that chronic stress have less cognitive bandwidth to make good decisions about smoking and alcohol and other things like that. And also, you know, living in poverty, some people just can't afford to eat healthy foods. In this country, healthy foods are actually more expensive for you and so. So trying to understand that if we want to shift those health behaviors and improve health outcomes, we really need to look upstream. So, you know, we use that term to mean, like, looking at the root causes of what those problems are, and really recognizing that poverty is one of the major root causes of those issues, and that if we don't address that, and if we sort of work on like, you know, Band Aid solutions, addressing just the health issues, those health issues are just going to keep arising and not getting any better.
Johnson: So you work with being a consultant to both state and federal legislators on like the design of the policies to alleviate poverty. What kinds of advice do you give to our lawmakers?
Hamad: Yeah, so I was lucky enough in the past couple of years to serve on a committee at the National Academies of Science, Engineering and Medicine. This was a committee that was, you know, congressionally mandated. So Congress asked the committee to try to understand the root causes of intergenerational poverty and to look at the evidence to find the best evidence-based solutions. And so that was, you know, really an amazing experience. I got to sit on a committee with other experts, including economists and child psychologists and an interdisciplinary group, and we got to look through the evidence and the research that's out there to understand what you know, like, Why? Why is this happening? Why are children growing up in poverty, remaining in poverty as adults, and what can we do to fix that? And so we really identified that it's, it's not just income. You can't just fix the problem by, you know, writing people a check that, you know, people living in poverty struggle with a lot of different things. And so we looked at the evidence and found that, you know, if you want to address poverty, you can also focus on housing, you can focus on nutrition, that it's really important to look at the local context, wherever that state or local policy maker lives, and understand what are the problems in my community, to really tailor the solutions and really that there's like a menu of options you could pick from to try to address poverty in a given community, and that really has to be sort of multi factorial, otherwise, you know, we're not thinking holistically enough about how to help people.
Johnson: You, in your talk this morning, which was fantastic, you talked about, you know, you had the map up, and even, like you pointed out with Georgia, because that's our summit's in Georgia this year, and how we there were certain policies that weren't enacted in states and the improvements. So can you talk about that a little bit, whether it was the earned income or the child credit a little bit?
Hamad: Yeah. The largest poverty alleviation policy in the US is the earned income tax credit and so people usually get it by filing their taxes with the IRS, and then at tax time, they get a particularly large refund to help lift them out of poverty. But then states also have their own earned income tax credit programs that can sort of supplement the federal EITC. And so what's interesting is that not all states have added their own EITC. About half of them have, and it really is a group of states, you know, across the political spectrum, showing that poverty alleviation really is a bipartisan issue, but there are many, like Georgia, where we are for the summit, that have not done so and that there's a lot of opportunities in states to make those changes. Similarly, the other policy that I talked about was the Child Tax Credit, which, again, states have the opportunity to add their own child tax credit on top of the federal program, and a handful of states have done it, but not all of them, and again, not not Georgia, where we are today, and that those are really opportunities for state policy makers to take action to address poverty in their communities, even when, you know, sometimes the federal government gets caught up and can't, can't take action on those policies for whatever reason.
Johnson: You know, I one of the data points that you shared was about one in four don't claim the benefit, but it may not be that they didn't claim it, they don't understand it, or to fill out complete paperwork or or didn't recognize that the dollars from share a little bit about that, and then maybe some we can chat about some interventions that maybe people can do in their communities.
Hamad: Yeah, so the earned income tax credit, I mean, many of our listeners today might not have even heard about it, even though it is the largest US poverty alleviation policy, and as the name suggests tax credit, it does require filing your taxes, and we all know filing your taxes can be really complicated, and that actually, to receive this particular benefit, the Earned Income Tax Credit, there's a whole other instruction manual that's about 40 pages long. That's really hard, really hard to navigate. I mean, even myself, I've tried to, like, put together case examples for my students, to have them try out figuring out whether they're eligible based on a little profile. And they struggle with it. And I struggle to even put together the example, because the instruction manual is so complicated, and we're asking regular people who are actually struggling in all kinds of other ways, that's why they're eligible for the benefit, to figure out this instruction manual. And so, like you mentioned, one in four Americans doesn't receive the Earned Income Tax Credit, even though they're eligible for it, and that rate is even worse among people who have lower income or who are younger who don't speak English as their primary language. And so there's a lot of opportunities to increase awareness of this program, but not just awareness, because it is just so complicated to even do the paperwork, to really meet people where they're at and try to figure out what are the concrete solutions to get people the help they need, referral to tax prep services or other social service organizations to really address poverty by just taking the money that's already on the table, waiting for them.
Johnson: Right, making sure that they get it. You know, when you mentioned that, and I was sitting there, and I'm always trying to figure out solutions to problems, I just, I can't stand problems that just, they're just a problem. And we know it's a problem, we talk about the problem. I really like interventions, and what can we do? So, you know, I'm in a hospital in the healthcare system in Mississippi and in Louisiana, and so very familiar with disparities. You know, usually 50, number 50 in some kind of bad health outcome. But, you know, I was thinking with the mandate from CMS right now on hospitals to commit to health equity, and they have to do their attestation annually. Now, in what is in their framework that they have to follow in their you know, hospitals are collecting social determinants of health data. Now, I do, after hearing this piece of solution, which is why I kind of wanted to bring it into our podcast and our time together to an actionable thing that I think hospital administrators and those in this space can do for their own workforce, because even within our hospitals workforce, we know that there are people who are still in the poverty level, even though they're working a full time job, and just the challenges and cost of things like how that could be an item on a commitment to health equity, even within their workforce, to whether it's partnering with CPAs or those that do tax preparations on pro bono, or even if your system had to fund right, whether it's education for your team members on, you know, are you eligible and working with them one on one to be able to get benefits? Those kind of things only help them be a better team member and employer, but it pulls it, just reduces, can't even imagine the amount of chronic stress that people are living through they're having to make decisions around housing, and am I going to lose a subsidy? And am I going to lose this Earned Income Tax Credit, or am I going to lose this child credit? And just some of the hoops and barriers that they are having to walk through that, you know, I may have never walked through or experienced because I didn't have to take that. You know, one of the things also in your talk, and I'd like you to expand on it around when people the challenges around like WIC, and when they may lose that and what people are going through. Can you talk a little bit about that?
Hamad: Yeah, yeah. So we were talking about how for the Earned Income Tax Credit, about one in four people who are eligible don't get that benefit. That rate of take up is even worse for some of the other social safety net programs out there. So you mentioned WIC, which is the special Supplemental Nutrition Program for Women, Infants and Children, and that is a program that provides nutrition and breastfeeding counseling to pregnant and postpartum women and kids under five. And we know that, you know, take up is decent for infants, kids under one, it's about 78% but then for pregnant women take up, is only 43% and then once you get to four year old, kids take up is only 25% so that means only one in four kids who's eligible for the benefit is actually receiving it. And for WIC also, we know that, you know, families have to, like, recertify each time to continue to receive the benefit, and it's just very challenging in context where they also need to show up for work every day to make enough income to perhaps qualify for some of the other safety net benefits that they're eligible for and that it's really hard for families to keep track of all of these safety net benefits, each of which has its own application, each of which has its own criteria, each of which has its own paperwork you have to submit to show that you qualify and that you know you and I were joking that doctors and healthcare systems are really good at filling out paperwork and forms. That's what I remember when I was practicing as a family physician, I felt like that's what I did a lot of the time. And so there's an opportunity there to help our patients have better health by helping them claim these benefits. That, you know that, that we're just, we're just sort of the, you know, doing sometimes our job as the middle man of helping connect people to the benefits that they're eligible for. And you're, you're totally right that that's true of a lot of the employees in health care settings. We know that a lot of people who live below the poverty line are working full time jobs, and that employers, by helping their employees be more secure, are really improving their own workforce. And, you know, employees can, you know, often, then feel appreciation, and you can sort of lower the turnover there of the employee workforce. So, yeah, I mean, I think there's a lot of opportunities for healthcare organizations to be those anchor institutions in their community to really improve well being and fulfill their missions.
Johnson: Absolutely. Also, you know, thinking about community awareness, our community leaders and entrepreneurs who own small businesses that, again, may employ a large number of minimum wage employees and helping them understand the socioeconomic impact, meaning, if you have a new mom and who is on a subsidized type program, and the things that she has to do to make sure that her child achieves all the eligible meet all the eligibility criteria. So you know, a newborn in that first year of life is going to the doctor once a month, then they go every three months, then it's every six months to get the necessary vaccines and making sure that they're doing the developmental screen. But as an employer, right of who I might not appreciate the reason my my individuals asking to be off, or need, needing to leave early, or maybe showed up late, but to me, if there's a level of community awareness around the struggle, so it's kind of like, how do we throw the pebble in the pond to have the ripple effect, so that people can appreciate the journey to improve the path that they're walking on.
Hamad: Yeah, yeah. And I think it is important for, you know, both employers and healthcare institutions and government officials to think about these policies that support families as an investment. So for example, you know one possible solution for the scenario you describe, where somebody's having to take off to take their kid to the doctor for the recommended appointments, is to offer paid leave to employees. And a lot of people are thinking only of the short term cost of that, oh, I'm going to, you know, that employee is going to be gone, I'm paying their salary when they're not here. But you know, research clearly shows the long term benefits of paid leave, that in a lot of cases, it actually keeps employees longer that it encourages people to stick with that employer. Again, reducing turnover makes employees healthier. So thinking of that long term investment in employees, in patients, in just members of our community, it really changes the story about you know, short term thinking to really long term thinking.
Johnson: Thank you so much for that added piece. Shifting back to policy makers. What are some things you think policy makers are maybe what they get most wrong when it comes to trying to alleviate poverty?
Hamad: Yeah. I mean, I think one of the biggest issues with the social safety net in our country is how many of the benefits are contingent on working, and that policy makers really have that lens, that in order to help people lift help lift people out of poverty, we have to only give benefits to people in the workforce to sort of encourage them to stay working, and I think that for the for the most part, that's a good idea, but what it leaves behind is the people who aren't able to work, who are either too sick to work, or they live in a community where there's not a lot of good paying jobs, or they're taking care of a sick family member, and so those most vulnerable people in our communities are actually not eligible for The majority of the social safety net programs out there, be it the income support programs or the nutrition support programs, and I think that's a big hole in our safety net, and that policy makers often aren't thinking about those people. They're so worried that if they offer benefits with no strings attached, that everyone's going to like quit their jobs and just to receive these benefits. And just to be clear, these benefits really aren't generous enough that you could live off of them without also working. And so what it does is it leaves these gaps for these families, and in particular, when we think about the children in these families, they have no control over whether their parent is working, or what sort of family they're born into. And so it really, you know, sets kids up for like, this intergenerational transmission of poverty and disadvantage. And so I think that's like the main gap in the safety net in our country that needs to be addressed.
Johnson: How have we in the past informed our policy makers who are making these level of decisions that serve on these types of committees. I mean, is there any type of formal kind of like, Hey, here's an orientation before you start making a decision. Is there, what do we do to help broaden their lens?
Hamad: So, I mean, there's my role as an academic, which is that whenever I do research studies that I think have that sort of impact, the potential impact on policy. You know, my job is to sort of develop the research briefs and try to try to get them to either the policy makers or the nonprofit organizations that can carry that message. But I think even as as people who are not in academia, in fact, I think they have an even bigger role that in their communities, they can advocate to their legislators or be involved in organizations that can push for these sorts of issues and advocate for these sorts of programs to benefit themselves and the more vulnerable people in their communities who need that help.
Johnson: I know. I'll do my part. I'll make sure, I'll send this podcast link to my senators and make sure that they know. So for folks working in healthcare and who have grown convinced that poverty alleviation is a critical piece of promoting health equity in their communities, what advice do you have for them regarding how to start working for change?
Hamad: Yeah. So in my talk today, I covered a commentary that I wrote a couple of years ago that was published in JAMA, where we outlined exactly these sort of four action items that people in healthcare systems can take in order to help bolster the safety net and support their more marginalized patients. So the first, which we sort of touched on today, is really help patients who are missing out on those benefits receive those benefits. And that doesn't mean that you necessarily have to bring like a tax prep consultant into your clinic, but a lot of times, you know, a lot of clinics have social workers embedded and making sure that the social workers are helping make those connections. Or, you know, a lot of clinics these days and healthcare systems are collecting information on Social Determinants of Health, if you know they're discovering that patients are struggling with those things, making the referral to social services programs, making the referral to volunteer tax prep organizations in the community to help people get the money that they already qualify for, but They're sort of leaving on the table. Another opportunity is related to payments from Medicaid and Medicare. So the Center for Medicaid and Medicare Services allows states to use funds from CMS to support social determinants of health to actually pay for housing and nutrition and transportation. Because even, you know, the Center for Medicare and Medicaid Services recognizes that investing in these social drivers of health improves health.
And so in a lot of states, that's a possibility, is using the CMS funds to support the social drivers of health. And in places, in states that haven't received those kinds of waivers, or if that feels like too big of a project to take on, again, there's that opportunity to refer patients to those social services, like housing support and that sort of thing. The third action item is for organizations that are involved in research and involved in training, places that are based at universities or in residency training programs, is to train the next generation of healthcare providers about these issues, to make sure that they're thinking critically about social drivers of health thinking outside of the box, that the solution to health disparities isn't always more healthcare, sometimes it's other things outside of healthcare. And potentially to help build that evidence base, we don't necessarily have all the evidence we need to know what is the best way to connect patients with social services, and to try to do you know, if not full on research projects, those quality improvement projects that a lot of places already do, to try to figure out the best way to get patients connected. And then the final thing is advocacy, a lot of healthcare, professional organizations and systems already do advocacy.
Usually, what they're advocating for is policies to improve their bottom line. But there are opportunities to do advocacy for policies that help their patients' health so that they can really fulfill their missions. And one example I gave during my talk today was the American Medical Association, they released a press release within the last couple of years advocating for increasing the minimum wage to keep up with inflation. And you know, I think historically, people would have not predicted that the AMA would be advocating for minimum wage policy, but I think there is that deeper recognition now that investing in social drivers of health is going to improve health. And, you know, that's why a lot of us went into this field to become, you know, healthcare providers.
Johnson: Yeah, change agents too, right?
Hamad: Yeah, exactly, yeah.
Johnson: I think, you know, with CMS mandate, and then we have other agencies, like the Joint Commission, et cetera, that have the social drivers of health, or the health equity kind of lens that says, hey, this is what we want you to do, you gotta do a framework, you gotta do an attestation. You gotta devote leadership to it in the challenge. So I think the fact that now we're measuring it within our own community, right? We've always done things like the community health needs assessments and really looked at these issues, but now we're kind of peeling the onion back and looking at the patients that we serve. And it can be challenging on, you know, helping providers, clinicians, nurses, therapists, social workers. You know, the, Why do I have to ask this? And then the concern that I'm asking some of these very personal right questions, helping them frame it in a different way. These are really, really benefit their health, and educating them on the why, so that they can embrace it and the linkage that we're closed loop referral, I think, can be the most challenging. So again, understanding your community, the resources you know, I know some hospitals are having to invest in using third party vendors just to be able to do a closed loop or find those resources to connect.
So I know it's a challenge, but I know it's a, once we kind of spotlight it, then we know we can do something right? It's when something's in the dark, yeah, when something's hidden, that's when we can't do anything about it. But I think when we start spotlighting and showing the problem, and then people can use their empathy and go, wait, this is inequity, and we can do something better. I think that's when we can really see the change. So, you know, sometimes we don't like some agency telling us that we have to do something, but sometimes it is necessary for us to do the right thing. The policy making that you do, and the leadership you're leading, there is really an upstream which is so important, and I think where we catch the boss so downstream, right? So can we just talk a little bit more about upstream actions and then so that, as we tie it all together and wrap up, are there final words around really making these upstream actionable items?
Hamad: Yeah, no, totally. I mean, I think that, you know, when we talk about health inequities, we need the sort of downstream solution in clinical settings, meeting people where they're at in terms of improving their health through healthcare interventions. But we also need to think about upstream again, those root causes addressing poverty through larger policies at government levels, either state or federal government. And I think one thing that gives me hope is that we know a lot of those solutions. So for example, during the pandemic, it was really kind of amazing. Amazing to see how policy makers reached across the aisle, had these huge expansions to the safety net, to increase the generosity of nutrition programs, to improve income supports, to make people's housing more secure, that in that crisis moment, people got it done, and they made changes to the safety net that I think many of us studying the safety net would have thought wouldn't have been possible for decades, if ever. And that, you know, and those of us who do this kind of research saw that those programs had a really positive impact. So the thing that gives me hope is that we know some of those upstream solutions, we just have to find the political will as a country to make those changes, and that, you know, part of that is on policy makers, but part of that is also on, you know, us as constituents advocating for those changes with those who represent us, to make sure that we are focusing in our communities, but also upstream, so that, so that these challenges are sort of addressed on a more population level, even wonderful.
Johnson: And that is the wrap up. I just, I thank you so much for just pulling it all together and ending in advocacy, because that allows every one of the listeners here to really understand what their individual role is, and now that we've spotlighted the challenges and the problems and then what are the upstream and the downstream solutions, I just want to thank you again for for sharing your expertise and your passion with us today.
Hamad: Thank you so much for having me.
Johnson: You can find links to more information about Dr. Hamad and her work on poverty alleviation and Health Equity at the link in our show notes. And that brings us to the end of another episode of the health disparities podcast, from Movement Is Life. I'm Dr. Charla Johnson. Until next time, be safe and be well.