Cash as Medicine in Flint, Michigan.

Check out what's in stock at crooked.

com slash store for this month only. America Dissected is brought to you by the DeBeaumont Foundation. If you're in public health, understanding policy is part of the job. Sharpen your skills and expand your knowledge with strategic skills for public health practice, policy engagement. A new book from the DeBeaumont Foundation and APHA Press.

Policy engagement demystifies the policymaking process and gives readers the tools and confidence they need to pursue bold change. To learn more and get your copy, visit DeBeaumont.org.

President Biden announces a plan to expand prescription drug negotiation as Big Pharma seeks to block it in court. Measles begins to spread in Florida as its state government ignores obvious public health recommendations. The state of Alabama passed a law protecting IVF, but it fails to settle the key legal debate in question. This is America Dissected. I'm your host, Dr.

Abu El-Sayed.

Friends, if my voice sounds a little bit muffled today, it's because I'm just getting over something. And before I get started, I want to share something we're working on here at America Dissected. We know that a lot of you are healthcare providers, and we were thinking, what if you could earn continuing medical education or CME credits just for listening? If you're interested and you want CME credits for listening, go on over to americadissectedcme.com to fill out a quick two-minute survey to let us know a bit more about what you need. That's americadissectedcme.com.

Again, americadissectedcme.

com. Now to today's topic. You all remember these headlines.

A few months back, we had Professor Luke Schaeffer on to talk about his book, The Injustice of Place, an anthology of America's poorest communities, basically all the other Flints that dot America's geography. And one of the things that he pointed out that had never really crystallized for me was how so many of America's bus towns had been boom towns in the past. Flint is emblematic. It used to be one of the richest cities in America, if you can believe it, a place where people went to build cars. And with them, their American dreams.

Folks came to Flint from all over the world, including from the American South. But they were black, which meant that they traded southern racism for northern racism and were shunted into the worst jobs with the worst pay, forced to live in the worst neighborhoods and send their kids to the worst schools. Redlining created two versions of Flint, just like it did for so many Midwestern manufacturing boom towns in the early to mid 20th century. But the cars were still rolling off the assembly line, and jobs meant that people could still live out their American dream. Until, of course, the cars stopped rolling.

In the 80s and 90s, free trade deals and globalization meant that more and more of the big three's production moved abroad in search of cheaper labor. One by one, the hawking factories that produced those cars and those livelihoods began to shudder. While wealthier, whiter Flint found its way to other opportunities, poorer, blacker Flint could not. By the end of the 1990s, Flint had become one of America's poorest cities. And, rather than pump new economic opportunities into the community, Michigan's state government lashed it with economic austerity.

In 2011,, then-Governor Rick Snyder appointed an emergency manager to oversee the city's operations with just one goal, reduce the city's debt. Saving money trumped protecting lives. And when the city had a chance to cut costs for its water source, they made the disastrous decision to move Flint off of Great Lakes water and onto Flint River water. The same Flint River that caught on fire because all those factories used to dump their waste into it. That water was more acidic, and, as a result, it stripped the protective algae lining and ultimately the lead from the pipes that carry water underground.

And that lead, well, we all know it wound up in the cups and pots and baby bottles feeding Flint's kids. As Luke explained the last time he was on the show, there are dozens of Flints with their own stories about the way that America's uniquely exploitative brand of corporate capitalism creates false promises, strips communities of their resources, and leaves their poorest people even poorer. And in many of those places, elected officials failed to respond accordingly. For example, as the Flint water crisis was unfolding, the state tried to deny it. It took the heroic voice of Dr.

Mona Hanna-Attisha, a Flint pediatrician and epidemiologist, to prove it was happening. One of the most frustrating parts is that Flint didn't even require a complicated solution. It turns out that just a few bucks a day could have added corrosion controls to the water and protected Flint's kids. A few bucks a day. If a few bucks a day could have saved Flint's kids from disaster, what could 500 bucks a month do?

That's the question Luke and Mona are asking now. With the support of the state of Michigan and multiple philanthropic funders, including the Flint-based Charles Mott Foundation, they've launched an innovative new program. If the problem is poverty, and has always been poverty, then what would happen if you just gave moms and babies the money they needed? They're offering pregnant folks in Flint $1,500 a month for the duration of their pregnancies and an additional $500 a month for the first year of their baby's life. If you're doing the math, that's an average of $19,500 per person.

I wanted to learn firsthand what that would mean for Flint families, how the program came together, and where it could go from here. So I invited Mona and Luke back on the show to share more. Here's my conversation with Dr. Mona Hanna-Attisha and Professor Luke Schaefer.

Because I think the last time most listeners heard about Flint, it was the Flint water crisis. So can you tell us about how far Flint has come? Where are we today?

They think governmental neglect. They think of this egregious story of how we really failed to protect children. And from kind of the moment of recognizing and really uncovering this kind of terrible injustice, the community has kind of rolled up their sleeves and tried to mitigate the impact of this crisis and promote the health and development of children. So for years now, we've put into place things like expanded early childhood placement and literacy programs and expanded Medicaid and nutrition prescriptions and trauma-informed care and mental health services. So this goes on and on.

of all the amazing things that we've been able to put into place in Flint. A lot of that is weaved together through the Flint Registry, which is a CDC-funded effort to see how folks are doing, but, more importantly, to get them connected to all these really awesome secondary prevention resources. So I continue to practice in Flint. I continue to see our kiddos. And despite all this awesome that we've been able to do since the water crisis, there's one thing that we haven't been able to treat, and that's poverty.

And that's kind of how our kids got started.

And then you have, as you mentioned, not just poverty, but concentrated poverty. So, you know, the decline of a city that just a few decades ago was one of the richest in the entire country to one where today we have the highest rates of poverty in the state. You know, huge rates of child poverty all across the city. And so it's one thing not to have enough, but it's another thing to be in communities where no one has enough. And those challenges can be real.

And I think the story of the city that really came together after the water crisis and in so many ways is leading the nation, you know, leading the nation, and new rules for water, water pipes, water infrastructure. And now in our kids, makes it even more remarkable.

Families with kids have higher rates of, you know, challenges putting food on the table. They have bigger challenges paying the rent or paying the utility bills. And of course, they have all these other added expenses, which are a big part of that. Childcare. Just the transportation costs, right, of keeping a family going.

More, more clothes, more food for the family. And you've got seniors who actually have just like the most robust safety net that we have through Social Security and Medicare. that takes the form of monthly money to help families make ends meet, the ways that they see best. And then provision of health care. And we can see that in the lowest rates of food insecurity.

So there's a lot of seniors who are struggling, but on the overall levels, they are the sort of best off group because they have this more robust safety net. And we've never had that for kids. It's always been a mishmash of different programs. They don't work well together. None of them provide enough.

They're stigmatized. And through this project, one of the things that we've really gotten a lot of clarity on is all of these challenges are actually the biggest during that first year of life. So poverty over the course of the life course actually starts to spike. It spikes right at childbirth. It's, you know, poverty starts to go up a few months before childbirth.

It's the highest point in the life course, as moms are able to work less and the added expenses of a new child come into play and then stays elevated. through that first year. Child welfare actually is another one where you're more likely to lose your child because of neglect, which is, you know, highly correlated with poverty. Not being able to care for your children because of financial circumstances happens in that first year, too. So Flint is a very, very poor city, but there are many other cities.

And actually, one of the things that we're learning now is that rural areas exhibit a lot of the same challenges, that we have. Extremely deep, concentrated disadvantage across, you know, many different dimensions in rural areas, too.

What happens in that window of life really kind of, you know, portends your life course. And we as a nation allow our youngest families to struggle so much, and we don't have to be that way.

And the other statistic that you get right around this time of year is that our birth rates are declining. And the crazy thing is, you know, all three of us are parents. All three of us have done this thing of trying to figure out how to care for an infant. But, like all three of us have done it with a upper middle income salary. And it's still really hard.

And you wonder why people don't have kids. And it's because it's an entirely difficult thing to do, because we make it so hard and we don't offer you almost any support to do it. And then we sit here and wonder, you know, this is the funny thing. The same folks who seem to worry so much about our economy, right, they don't realize that that economy is going to be – it's going to be the sum total of these folks growing up in circumstances where they can become both producers and consumers. And so like we're like a penny rich and a dollar poor, because we're not willing to invest in this early point in life to like subsidize American young people having more young people, which is what keeps an economy in a country going.

And it's just – it's crazy to me. So I want to zoom in on this idea. Mona, tell us a little bit about RxKids. What is it? How does it work?

And why are you so excited about it? Because I know you're super excited about it.

So, once again, this is for every mama, every baby. No means testing, no income testing. This is universal. And we are doing this for many reasons. We're doing it to eliminate infant poverty in one of the poorest cities in our state.

We're doing it to improve health and equity, improve opportunity. But we're also doing this to almost reimagine that social contract. This is fundamentally how we should be taking care of each other. This is normal in other countries. In the Global South and Western countries, child allowances are normal.

Child benefits are what folks do. So we're doing this in a way that is building trust with dignity and really kind of enveloped with love. Once again, this is how we're supposed to care for the youngest folks in our society.

What are the outcomes when you start investing in families like this?

They see kids do better in so many different ways. And the logic behind it is that families lives are complex. I mean, just as you mentioned, we've all raised kids. We all have challenges. Some of them are the same, but people's lives are different, and they might have access to housing, but they need help with food, or they need help with transportation, or they might have no housing.

They might. they might have access to transportation or food, and they they need housing. And so when we ever, we as society, say we're going to offer you this thing because we think families need child care, for example, it's going to work really well for some families, but it's actually going to miss the mark for other families. So using cash is making a statement about empowerment and giving families the choice, because we decide they they're the ones who know the best about what their families need. And they can allocate resources in the way that makes the most sense for them.

So this has deep roots and libertarian thought. Milton Freeman was a very important early advocate of using cash transfers to fight poverty. And we have a ton of evidence now that families really use the money wisely. So we might spend a little bit of time talking about the expanded child tax credit. One of the things that I like best is not only did it drive child poverty to an all time low, did it drive food hardship to an all time low?

Not only did we see parents have better mental health outcomes. It also, at the end of 2021, the fewest families had low credit scores. And as far back as we've been going, because families use the money to pay down debt or make really smart investments. So cash is empowering to families. The other strong policy argument for it is it's efficient.

We we saw this during the pandemic, where we had cash transfers like the economic impact payments and the child tax credit. Those rolled out very quickly. There's a lot of evidence that they saved us from economic cataclysm. And we had other programs, too, around, like housing, eviction prevention programs. And those are really important, too.

But they took a really long time to set up because they're more complicated. States had to create plans on how they were going to actually process families, make sure they were eligible, income eligible and figure out how to send the money to landlords and how much would be sent and what the landlords would have to do. So money is just a much simpler way to do it. So, you know, if you're a believer in small and limited and efficient government, this is the type of program for you.

They were just irresponsibility, or that giving people access to, you know, to government resources was itself a shameful thing. And that that would hobble their capacity to be in due. You talked a bit about the debt pay down. Where did most of this money go? How did families spend this money in terms of the kinds of circumstances to cover?

Because, you know, one easy way metaphor to think about poverty is a blanket that's just a little bit too small. You know, and here in Michigan, when you think about cold nights, you want a very big blanket because you want to make sure that your entire body is covered as you need it to be. But if your blanket is too small, then you got to choose. Am I covering my chest or am I covering my feet? Do I want to keep my arms under or do I want to keep my legs under?

And, you know, you think about that metaphor. Do I want to pay for my heat or do I want to pay for my rent? or do I want to pay for my food or do I want to pay for my kids, school? Do I want to pay for my car? Do I want to pay for my insurance?

Like these are the things that people are choosing. How do people use this money when they get it?

And the answer is the single biggest expenditure is food.

But there is this sort of marginal propensity for families to spend it specifically on ways that they benefit the kids. So diapers, but also books and toys, things like, you know, enrichment activities. So there's. no, it's not restricted. We're not saying you have to do that.

But families, do, you know, when the money is coming for the kid, it seems it has a lot of meaning to parents to try to use in the ways they see best.

And, you know, it's funny, because so many of the things that folks have labeled this narrative that we've accepted about what frivolity is based on, this sort of welfare queen narrative. When you actually dig deep and you start thinking about, you know, a purchase of a toy for a child, what you're literally doing is you're investing in that kid's mind's ability to manipulate, which is like fundamentally what cognitive capacity is. And I mean, it's such an indictment on us that we've accepted this idea that has kept so many families from being able to feed their kids, keep a roof over their heads or keep their minds occupied and grow them. I want to ask you, Dr. Money, you know, you minister to the health of kids in Flint.

Yeah. As you think about where this money will go, you know, walk us through, where you see it impacting the lives of the kids you take care of.

And 60% of those moms, the household income is less than $10,000 a year. Think about that. The household income of 60% of our moms is less than $10,000 a year. And 90% of those moms, the household income is less than $30,000 a year. I share this story a lot now.

We had a four-day-old who missed their appointment. And when our clinic asked, and this was a preemie, it was born at five pounds, they needed to come in for their newborn follow-up. And they asked, like, why didn't you come in? And the mom said she had to go back to work at four days of age. Wow.

Four days of age. She just delivered a baby and she had to go back to work.

Join host Dr. Adrienne Foo-Berman for her evidence-based, edgy, and entertaining approach to health and medicine. Each episode features an interview with experts and provides listeners with resources to learn more about how the pharmaceutical and medical device industries influence medical knowledge and public health. Previous episodes cover weight loss, drugs, mild cognitive impairment, and Alzheimer's disease, ADHD, unnecessary surgeries, and much more. Farm Manipulation is a podcast by Farmed Out, a rational prescribing project at Georgetown University Medical Center, and you can find their show anywhere you get your podcasts.

Are you ready to break free from the confines of traditional book clubs? Introducing Reading for a Liberated Future, the Marguerite Casey Foundation book club, where bold ideas, new visions, and daring experiments converge. Say goodbye to the same old narratives and hello to a vibrant, beloved community pushing boundaries and challenging norms to create a better world for everyday people. Each month, the MCF book club will bring you an insightful conversation with luminaries of our time who are speaking truth to power and doing the hard work of shaping a liberated future. Register for the Marguerite Casey Foundation book club today to get the latest information about their upcoming events and a chance to have one of their book club featured titles sent directly to your door for free, while supplies last.

Join the MCF book club at caseygrants.

org slash book club, that's C-A-S-E-Y-G-R-A-N-T-S dot. org slash book club.

We don't have to figure out who's in and who's out and what documents you need. It's very easy and efficient to administer a program that's universal. Not everybody has to accept it. If you don't want to accept it, you don't have to. Nobody has said that.

And they would figure it out on the back end, exactly like we're doing with AHRQ's kids, because we have state money that's paying for lower-income kids. And then we have philanthropic dollars that are paying for the higher-income folks. But from the front door, it's seamless. Families, you know, aren't differentiated. And the single biggest impact of making nurse home visits available to everyone was to increase the number of low-income families who took it up.

So families who were already eligible for it, maybe they, you know, it was more straightforward. They didn't have to wonder if they were eligible. They didn't have to go through, as Mona said, some huge eligibility thing, you know, filling out forms with maybe lots of intrusive questions.

You know, there's always debates about Medicare, but they're not serious. Everybody knows that this has become a fundamental plank of any pro-middle-class policy in America. And even the same, you know, wealthier folks who may disagree with Medicare in principle, they're not ashamed to take Medicare dollars. They're not ashamed to use Medicare or Medicare Advantage. They're not ashamed to collect on their Social Security.

And so, you know, when you have a united community around a particular policy, you're right. That animosity goes away. The other part of it is, from a bureaucratic standpoint, the means-testing that goes into this adds so much cost to these programs. And this is the thing people don't appreciate, is that, like, you, create two problems. One is the actual monetary cost of having to hire a whole arm of bureaucracy intended specifically to create a bunch of barriers to getting the outcome of the policy.

But then the other part of it is that there's a broader cost to it, which is then you create this situation where you even create this, like, fraud situation, where you're like, oh, these people cheated the system. And if you just said, hey, no, this is actually for everybody, this whole idea that there can be fraudulent use of a public good that should empower everybody goes away. And so we've, like, manufactured a added cost in government. And it's funny, because it's the same people who talk about wasting government that tend to manufacture these artificial arms of bureaucracy intended specifically to keep people from getting a public good. It makes zero sense.

And, like, you know, working in government, the amount of time that you spend just auditing to make sure that the right people got it and the wrong people didn't, right, is such a waste of staff time. And such an occupation of your mind that could be used to actually provide people good things rather than take them away or decide who gets them and who doesn't.

All kids need to eat. All kids need at least two healthy meals a day. And, you know, there's not one line for some kids and one line for other kids and forms to fill out. Everybody needs to be well fed.

And, you know, people have given up on that front in terms of the justification for this.

is, it's getting smaller and smaller as you move down. And that's a real problem because you actually need more people to, A, support the folks at the very top who are no longer working. And then, B, what people don't appreciate is our entire economy is founded on the consumption power of the American consumer. Like, that is what makes America, America. And until, you know, if we don't create more consumers who are also producers, but more so consumers, that is going to have a real impact on our economy.

And so it's funny, you know, again, to this point, that people are like, well, you know, we don't have the money to spend on things like this. Okay, just wait and see what happens. See what happens when, you know, when we fail to reproduce. And so, you know, to your point, like, we need to make it easier to have kids. And I think that's the baseline.

And it's interesting, based on what you just shared, Luke, that that policy alone doesn't solve for the problem. But what's really fascinating, though, is, you know, you think about it. I think about my generation. So I'm about to turn 40.. And I think about, you know, I got two kids.

I think about my brother, who's eight years younger than me. He's got one kid. And then I think about my little sister, who's 15 years younger than I am and doesn't have any children. But the economic outlook between me, my brother, and my sister, and what we believe we can afford, whether or not we think we can buy a home, like these things matter. And so, even if somebody were to give you $500 a month, if you have a child, the question of whether or not you get to raise that child in a stable home, like you can actually afford your rent or your mortgage, like that, is an open question in the United States.

And so it's not just this, like, cash transfer. It's also just the structure of our economic system that we really need to be thinking a bit about. And this is a really important contribution. in this respect. I want to go back to something that you raised earlier, which is the child tax credit, right?

And that was for all of us who've been paying attention to child welfare in this country, there was like a ray of hope that came through in the clouds and then all of a sudden closed up. And I want to ask, where do we think we stand in terms of being able to bring that back, to be able to scale something like the incredible program you talked about here, RX Kids in Flint, to hit low income families in urban and rural communities all over the country?

And then they got half of it on a monthly basis, $250 per kid, $300 per little kid, and then half of it on their taxes, a tax time. So I got to be a part of crafting that sort of structure with a set of colleagues back in like 2016,, 2017, after my my book Two Dollars a Day. And at the time we wrote up a paper about it and there were lots of champions in Congress that have been talking about the ideas for a long time, but it was really considered pie in the sky. I remember getting some comments back from some colleagues saying this is a wonderful idea that could never possibly happen in the United States. And so I think where we are now is that it wasn't extended after 2021, but it's no longer pie in the sky.

We did it and we saw the incredible impacts it could have. And right now in Washington, they're talking about doing an expansion of the child tax credit. It doesn't go nearly as far as what we had in 2021.. So my hope is that they won't become complacent. But, you know, Mona and I spend a lot of time in Washington talking about our kids and talking about kid policy.

And I can say that we're just in a fundamentally different place among many policymakers who think that this is the standard. And so that is very exciting. And what our kids really does is it says we don't have to wait for a major change in Washington. This is something that communities can do. And and the thing that really makes it scalable is the use of TANF dollars.

So that's a. that's a federal block grant, temporary assistance for needy families that states all over the country get. And it was. it's supposed to be used for cash welfare program. It came out of the 1996 welfare law, but it turns out it's really flexible money.

And so states have really misused it. I think people, you know, really pretty wide across the political spectrum agree the program is not being used the way it should be. And so our kids is historic in that the state of Michigan put TANF dollars towards this program. And that means that it's something where there's an annual funding stream that states could choose to use for this, for a set of communities or for statewide. And we are just hearing interest from all over the country, red states and blue states that say, you know, this could be a radically different way to use our TANF dollars that could really support families in a dignified way.

And actually has appeal across a broader spectrum of the political aisle.

It is an outlier in the world. We need to, you know, do things like the expand child tax credit and make it permanent. We need to do things like ARCS kids and make it permanent. We need to tackle gun violence. It's the number one killer of children is guns.

right now. We need to strengthen our environmental regulations so kids can breathe clean air and drink clean water. We need to raise the minimum wage so that, you know, families can support their children. You know, we need parental leave policies, you know, also, at par with other countries. There's a lot of things that we can do to protect the health and development of our children.

You know, we're celebrating RX kids. A lot of our work is about changing the narrative of how we treat children and families. So we're doing a lot of celebrations and there's a lot of happiness, and, you know, talking about our moms and babies. And we're celebrating RX kids. on Valentine's Day.

There's a big community-wide celebration. that's happening on Valentine's Day because fundamentally, this is about how you're supposed to love your children. And I'm really excited that we're doing this on Valentine's Day because it's also Frederick Douglass' birthday. It's a self-proclaimed birthday. And so much of my work and kind of the work of RX kids is guided by one of my favorite quotes of Frederick Douglass.

He said, it is easier to build strong children than to repair broken men. So RX kids is one way to build strong children rather than continue to do what we have been doing, which is repair broken men. And that's expensive and it really kind of shoots ourselves in the foot. That's not how you build a nation. That's not how you build a community.

That's how you invest, especially if you respect the science of brain development in early childhood. You invest as early as possible in kids.

A federal court judge in Delaware recently rejected AstraZeneca's argument that Medicare drug price negotiation was unconstitutional. The ruling rejected the absurd argument that somehow, by forcing them to negotiate over costs, the government was seizing their protected property. Instead, the fact that our government hasn't been negotiating more represents a corporate seizure of government tax dollars. But I digress. In addition, he announced a plan to extend the cap for out-of-pocket prescription drug costs at $2,000, beyond Medicare beneficiaries, to privately insured folks as well.

He also announced a White House initiative on women's health research. In other news, if you haven't heard... Tonight, the highly infectious measles virus is spreading across more of the country, including in Florida, where a concerning outbreak is growing. There have been dozens of cases of measles around the country, mostly from international travel. In almost every single jurisdiction, including the one I represent in Michigan, public health officials have been scrambling to protect folks from local spread.

But there is one major outlier. As I shared. a few weeks back, a batch of cases in Broward County, Florida, were met by the state's, quote, Surgeon General with the public health equivalent of a shrug. And guess what? There is solid evidence of local transmission in Florida.

I want folks to appreciate something here. Measles is imminently preventable. The vaccines work, which is why you haven't been hearing much about it now. But once measles takes hold, it'll exploit the crevices in our immunity. And those crevices aren't small anymore.

Vaccination rates are down significantly since COVID, and Florida is offering us a preview of what could come. Except in almost every other community in America, you bet that public health professionals will be pleading with folks to vaccinate or quarantine. I'll keep you posted. I fear this won't be the last time we talk about measles here in the near future. Finally, last week we spoke with Elizabeth Smith, the Director of State Policy and Advocacy at the Center for Reproductive Rights, about the disastrous Alabama State Supreme Court ruling giving IVF embryos the legal status of actual kids.

This week, the state legislature tried to do something about it.

Which of course implies that there are some kids in Alabama that can be killed with impunity. Again, more pretzel logic to justify a fundamental fallacy at the heart of all this, that the state can take away the rights of actual humans to honor the humanhood of a clump of cells. That's it for today. On your way out, don't forget to rate and review the show. It really does go a long way, and if you're interested in earning CME credit with us, let us know a bit more about you and your CME needs at americadissectedcme.com.

That's A-M-E-R-I-C-E-D-I-S-S-E-C-T-E-D CME.

com. And if you love the show and want to rep us, drop by the Crooked store for some America Dissected merch. Don't forget to follow us at Crooked Media and me, Ad Abdul El-Sayed, no dash, on Instagram, TikTok, and Twitter. Finally, I had the opportunity to do a cool interview with Melanie Sona and Aaron Litka on their podcast, Healthy Neighborhood, Healthy Nation. We talked about how we communicate science.

I hope you'll check it out.

America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Lickfried. Charlotte Landis mixes and masters the show. Production support from Ari Schwartz.

Our theme song is by Takai Sazawa and Alex Uriera. Our executive producers are Leo Duran, Sarah Geismar, and me, Dr. Abdul El-Sayed, your host. Thanks for listening.