For nearly a decade, Flint, Michigan has been synonymous with the lead and water crisis that put the city on the map. But Flint is resilient. Abdul reflects on the central role of poverty in all that Flint experienced. Then he speaks with Dr. Mona Hanna-Attisha, the pediatrician who uncovered the water crisis, and Prof. Luke Shaefer, an anti-poverty researcher, about their new “Rx Kids” program to provide cash to pregnant moms to solve poverty in Flint.

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TRANSCRIPT

[AD BREAK] [music break]

Dr. Abdul El-Sayed, narrating: 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. Abdul El-Sayed. [music break] 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. 

[clip of unspecified Flint, Michigan resident] What about all the other families? All the other kids in Flint? How do you sit by and let people be hurt and know about it and do nothing? 

[clip of unspecified Flint, Michigan resident] My youngest would tell me, mom, it’s yellow and it’s a filmy, gross, foamy thing and it would smell like an open sewer. But we were being told we’re still getting used to the new system. It’s safe. It’s okay. 

[clip of unspecified news reporter] But it wasn’t okay. Far from it [fading out]

Dr. Abdul El-Sayed, narrating: Thousands of babies and children poisoned by the very water intended to nourish them. I still, to this day, can’t imagine the agony of learning that the water you mixed your baby’s formula with might have irreparably damaged their brain. It’s a horror no one should have to go through. And what made it all the more galling was the fact that this wasn’t happening in some distant country without functional water infrastructure. It was happening here in the US. A brutal story about a community being left behind by America’s economy and neglected by the people elected to protect it. A few months back, we had Professor Luke Shaefer 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 bust towns had been boomtowns 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 boomtowns 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 hulking factories that produced those cars and those livelihoods began to shutter. 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 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 fail to respond accordingly. For example, as the Flint water crisis was unfolding, the state tried to deny it. It took the heroic voice of Doctor 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 need? 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 Doctor Mona Hanna-Attisha and Professor Luke Shaefer. 

Dr. Abdul EL-Sayed: Can you both introduce yourself for the tape?

Dr. Mona Hanna-Attisha: My name is Mona Hanna-Attisha, I’m a pediatrician in Flint, Michigan, and a professor with Michigan State University. 

Luke Shaefer: My name is Luke Shaefer. I’m a professor of public policy and director of poverty solutions at the University of Michigan. 

Dr. Abdul EL-Sayed: So I feel uh like we’re getting to have a usual conversation. I’ve gotten to know both of you really well over the past several years, and just really grateful for um your work. And um it was just a really exciting opportunity to have you uh to come talk about a piece of public policy for Flint that I think can be a game changer. But I do want to, to step back. Right. Because I think the last time most listeners heard about Flint, it was the Flint water crisis. So can you tell us about, you know, how far Flint has come? Where are we today? 

Dr. Mona Hanna-Attisha: Yeah, that’s a great question, Abdul. But uh, first, thanks for having us. We’re so excited to be on your podcast. We’re so excited to share this work with your listeners. Um. So yeah, I think most people, when they think Flint, they think of brown water, they think governmental neglect. They think of this egregious story of how we really failed uh to protect children. Um. 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, you know, tried to mitigate the impact of this crisis and promote the health and development of children. Uh. 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 the list 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. Um. So I continue to practice in Flint, uh I continue to see our kiddos. And despite all this awesome that we’ve been able to do since the water crisis, um there has there’s one thing that we haven’t been able to treat, um and that’s poverty. And that’s that’s kind of how “Rx Kids” got started. 

Dr. Abdul EL-Sayed: I want to talk a bit more about the program, but I do want to ask, you know, as I’ve heard you talk about Flint and, you know, as people talk about um what happened, obviously the the big story is how did the water get poisoned by lead? But the bigger story is probably the circumstances in which the the water was poisoned. This is a city that has been hit by compounded levels of poverty. Can you tell us uh, Luke, about about compound poverty in Flint kids, what are what are the circumstances in which Flint kids are living? And um how should we understand the impact that that has in the various, opportunities that they might see in their lives? 

Luke Shaefer: Well I think the water crisis was just it was the acute crisis that um, built on uh decades of of challenges. So you had the decades of challenges of um deindustrialization and a city that really led the way in so many ways, you know, built cars um that really, you know, had a thriving middle class. Where unionization came, uh really, uh in many ways uh was born and, and flourished in some ways. But then you had this decline, uh that one industry, you know, you have a broader state that put all of our eggs in one basket. And then uh and then you have, as you mentioned, not just poverty, but concentrated poverty. So uh, you know, the decline of a city that just a few decades ago was one of the um richest in the entire country uh, to one where today we have the uh highest rates of poverty in the state um you know, huge rates of child poverty all across the city. And so it’s one thing uh not to have enough, but it’s another thing to uh be in communities where uh no one has enough. And uh those challenges can be real. And I think the, the story of the city that really came together after the water crisis and in so many ways is is leading the nation um, you know, leading the nation in new rules for uh water, water pipes, water infrastructure. And now in “Rx Kids” makes it even more remarkable. 

Dr. Abdul EL-Sayed: I want to ask you, because I think what what a lot of folks don’t understand is we have a couple of compound child crises. What people don’t appreciate and and this is the thing that always kills me whenever I hear these statistics. And they come out every year whenever data gets collated, is just how young the locus of American poverty really is. The fact that poverty tends to concentrate in families with children. So we’re talking about Flint today. But how common is the Flint Kid experience, around the rest of the country? 

Luke Shaefer: Well, you’re absolutely right. Um. Pretty much any marker of financial well-being that we look at, uh families with kids are at the top, right? Uh. Food insecurity. Families with uh 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. Uh. And of course, they have all these other added expenses, which are are a big part of that, uh childcare um just uh transportation costs, right, of uh keeping a family going. Uh. More more clothes, more food for the family. And you’ve got uh seniors who actually have just like, the most robust safety net, uh 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 uh and then provision of health care. Uh. 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 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. Uh. They’re stigmatized. And and through this project, one of the things that uh, 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 child uh birth. It’s, you know, poverty starts to go up a few months before childbirth. Hits the highest point in the life course, as moms are able to work less and the added expenses of the new child come into play and then stays elevated through that first year. Child welfare actually is another one where you’re you’re more likely to lose your child because of neglect, uh which is, you know, highly correlated with poverty, not being able to care for your children because of financial circumstances. Uh. It happens in that first year, too. So, um 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 uh exhibit a lot of the same challenges that we have extremely deep uh concentrated disadvantage across, you know, many different dimensions in rural areas, too. 

Dr. Mona Hanna-Attisha: You hit it on the nail. Like they the younger the family, the poorer the family. Um. The fact that poverty spikes around childbirth and is the worst for that first year of life, that’s that’s maddening for a pediatrician and a public health person. Like that is the most critical time for child development. What happens in that window of life really kind of, you know, portends your life course. Um. And we as a nation allow our youngest families to struggle so much, and and we don’t have to be that way. 

Dr. Abdul EL-Sayed: I really appreciate that. And it’s a pretty crazy thing. Look, I love Medicare and Social Security. I think they’re amazing programs, and we ought to do more of them. That said, it is a crazy thing that we wait to invest in you, in this country until you’re over 65. 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 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 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 a an economy and a country going. And it just it is it’s crazy to me. So I want to zoom in on this idea. Um. Uh. Mona, tell us a little bit about “Rx Kids”. What is it? How does it work? Uh. And why are you so excited about it? Because I know you’re super excited about it. 

Dr. Mona Hanna-Attisha: [laugh] Yeah. Um. I’m super excited about it. Um. So “Rx Kids” is our nation’s first ever citywide maternal and infant cash prescription program. So this has never happened before. Every pregnant mom in Flint gets an unconditional uh cash prescription at mid pregnancy. After 20 weeks of pregnancy of $1,500. Um. And then once the baby is born, it’s $500 a month for the first year of life. Uh. So once again, this is for every mama, every baby. No means testing, no income testing. This is universal. And, um we are doing this for many reasons. We’re doing it to, you know, eliminate infant poverty in one of the poorest cities in our state. We’re doing it to improve health and equity, improve opportunity. Um. But we’re also doing this to, to almost reimagine that social contract. Um. This is fundamentally how we should be taking care of each other. This is normal in other countries. You know, in the global South and Western countries, this is child allowances are normal. Child benefits are what folks do. Um. So we’re doing this in a way that is um building trust, uh with dignity. Um. And really kind of enveloped with love. Like, once again, this is how we’re supposed to care for the youngest folks in our society. 

Dr. Abdul EL-Sayed: Yeah, that just makes, like, super obvious sense. And I’m really grateful that you all are doing it. I know that there’s just a lot of research that goes into this and um, and Luke you know, last time we chatted, we talked a bit about, uh unconditional cash uh transfers, which is the public policy jargon term for um a universal basic income. Can you tell us a little bit about some of the research base? What are the outcomes? Um. When you start investing in families like this?

Luke Shaefer: All of my research focuses on child benefits. As Mona mentioned, this is a, a policy that is common all around the world. Actually, Mona is a beneficiary of a of a child benefit, having been born in the UK. Um. And I really consider it to be the evidence based policy of evidence based policies. Uh. Because every time a country adopts something like this, they see their child poverty rate plummet. They see food hardship plummet. They see kids do better on, in so many different ways. And the, 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 uh people’s lives are different, and they might have access to housing. Uh. But they need help with food, or they need help with transportation, or uh, they might have no housing. They might they might have access to uh transportation or food. And they, they need housing. And so when we however we, as society say, we’re going to offer you this thing because we think families need childcare, for example. Um. It’s going to work really well for some families, but it’s actually going to miss the mark, uh for other families. So using cash uh is making a statement about empowerment and uh 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 a way that makes the most sense for them. Uh. So this uh, has deep roots in uh libertarian thought. Milton Friedman was a very important early advocate of uh using cash transfers to fight poverty. Um. And uh, we have a ton of evidence now that families really use the money wisely. So uh, we might spend a little bit of time talking about the expanded child tax credit. Um. One of the things that I like uh 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 um parents uh, have like 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, um cash is empowering to families. The other um strong policy argument for it is it’s efficient. We uh we saw this during the pandemic where we had cash transfers, like the economic impact payments and the child tax credit. Uh. Those rolled out very quickly. Uh. There’s a lot of evidence that they saved us from economic cataclysm, and we had other programs too. Around like um housing, you know, eviction prevention programs. And those are really important, too. But they took a really long time to set up because they’re more complicated. You know, states had to create plans on how they were going to actually process families, make sure they were eligible, income eligible, and um, you know, figure out how to send the money to landlords and uh how much would be sent and, and, 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 and limited and efficient government, this is a type of program for you. 

Dr. Abdul EL-Sayed: I want to um, just follow up. We have reams of data about actually the the child tax credit. And I want to, you know, get back to that on the back end as well. But where do families tend to spend the, the majority of their money? Because, you know, one of the things that happened in American, I don’t have to tell you this, but the listeners uh know, I, I, I harp uh on the Reagan era quite a bit because one of the things that happened wasn’t just policy change, but it was a narrative change that created the space for policy change, that told us that things like debt weren’t a function of lack of access to basic resources, they were just irresponsibility. Or that uh giving people access to, you know, to to government resources was itself a shameful thing. And that that would hobble their capacity, uh to be and do. You talked a bit about the the, you know, debt paydown. What where did most of this money go? How did families spend this money? Um in terms of uh the kinds of circumstances it covered, because I, you know, one one easy way metaphor to think about um poverty is a, is a blanket that’s just a little bit too small. You know and here in Michigan, when, you know, when you think about uh cold nights, you want a very big blanket because you want to make sure that your entire body is as covered as you need it to be. But if your blanket is too small, then you got to choose do I, am I covering my chest or am I covering my feet? And 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 kid’s school? Do I want to pay for my car? Do I want to pay for my insurance? Like, these are the things that that people are choosing. How do people use this money uh when they get it? 

Luke Shaefer: So we have uh, as you say, lots of evidence on this using tons of different sources. We have surveys asking people how they use it, uh there’s, you know, a huge data infrastructure on like, credit and debit card expenditures now. Uh. We have uh different um RCTS that have done some of this too. And, and the answer is the single biggest uh expenditure is food. 

Dr. Abdul EL-Sayed: I just want to stop there for a second. You said food.

Luke Shaefer: Food. Yeah. 

Dr. Abdul EL-Sayed: Like literally feeding your children is the single, single biggest thing. So you ask yourself this, what would happen if that money didn’t exist? I mean, you’re literally talking about putting food in a baby’s mouth or taking food out. 

Dr. Mona Hanna-Attisha: We see what happens. We we see it in uh failure to thrive in clinic. We see it also in childhood obesity, uh because sometimes, you know, processed foods, fast food is cheaper. Uh. So we see the consequences of food insecurity every day in our patients and in their potential. 

Luke Shaefer: And we, we put the child tax credit, the expanded 2021 child tax credit in place. And we saw, food hardship among families with kids particularly just plummet to the lowest level ever recorded. Huge drop. And then in 2022, it went back up. Millions and millions of more kids. So that’s a, that’s a decision we’ve made as a country. So uh, one thing that’s really interesting is when you sort of designate money for kids, a lot of it gets spent on household essentials, but there this sort of marginal propensity for families to spend it specifically on ways uh that they that benefit the kids. So uh, diapers, but also books and toys, uh things like um uh, you know, enrichment activities. So there’s no it’s not restricted. We’re not saying you have to do that, but um, families do you know when the money is coming for the kid, it seemed it has a lot of meaning to parents to try to to use in the ways they see best. 

Dr. Abdul EL-Sayed: You know, one of the things you said about about toys, you could imagine somebody who disagrees with a program like this saying, see, they spent it on frivolous things like toys, but like, you know, what are we but, you know, brains with bodies. And what does a brain do except for manipulate the world around it, right? In this abstract space that we think of as like the stage of our mind. And what is a toy except for the ability to, you know, to to have a thing to manipulate. And, you know, it’s funny because so many of the things that 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–

Luke Shaefer: Right. 

Dr. Abdul EL-Sayed: –to manipulate, which is like fundamentally what cognitive capacity is. And I mean, it just 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 um Dr. Mona, you know, you minister to the health of of of kids in Flint. 

Dr. Mona Hanna-Attisha: Yeah. 

Dr. Abdul EL-Sayed: As you think about where this money will go, you know, walk us through where you see it impacting the lives of the of the kids you take care of? 

Dr. Mona Hanna-Attisha: Yeah. So, you know, the the program launched in January. So we have about 300 moms who’ve already enrolled. And we have a little bit of data so far. And um, 60% of those moms, the household income is less than 10,000 a year. Think about that. The household income of 60% of our rural 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 but I we had a four day old who missed their appointment, and when the our clinic asked and this was a preemie. It was born at 5 pounds. They needed to come in for their newborn follow up and they asked like, why why didn’t you come in? And the mom said she had to go back to work at four days of age. 

Dr. Abdul EL-Sayed: Wow. 

Dr. Mona Hanna-Attisha: Four days of age, can like if, she just delivered a baby and she had to go back to work. 

Dr. Abdul EL-Sayed: That’s insane. 

Dr. Mona Hanna-Attisha: Um. So our, you know, I hope that these dollars provide a little bit of family financial security. Uh. So moms don’t have to go back to work at four days of age, and they can feed their family, and they can pay their debt, and they have a roof over their head, like, it’s not the answer to everything, but we hope it provides a little bit of buffer to what we are seeing as kind of extreme poverty as expected, because these are really young families. [music break]

[AD BREAK]

Dr. Abdul EL-Sayed: While we’re we’re tearing apart the Reagan-ite narrative here. I do want to. I want to float some questions that I’m sure, uh conservative folks would say, what about the idea that you’re going to give some of this money to people who don’t need it? Surely there’s a couple of families in Flint that aren’t poor, and so now you’re going to give them $500, every month? How does that make any sense? Shouldn’t we be be assuring that only the people who get, or who need this service, get this service? 

Dr. Mona Hanna-Attisha: Well, I think we we both very much, agree that it needs to be a universal program. Uh. Evidence all over the world is if you don’t include the middle class or everybody, then you create animosity towards a program because everybody is struggling. Like we said, raising a kid is hard. So we want this tent as big as possible. When it’s a universal program, there’s also less administration. We don’t have to figure out who’s in and who’s out and what documents you need. It’s very easy to administer and efficient to administer a program that’s universal. And folks who don’t want if they [?] if not everybody has to accept it. If you don’t want to accept it, you don’t have to. Nobody has said that. 

Luke Shaefer: Abdul, one of a, the studies that I found really interesting is uh, from some colleagues who were studying, like, nurse home visits in a in a community and the nurse home visits have been available to uh low income families for a long time. But the take up was really, really, really low. And so one of the policy prescriptions that they had was to make uh the take up universal. And so, they just said, you know, if for all families, this is available to you if you want it, and they would figure it out on the back end exactly like we’re doing with RX 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 uh, nurse home visits available to everyone was to increase the number of low income families who took it up. So the families who were already eligible for it, maybe they, you know, it was uh, more straightforward. They didn’t have to wonder if they were eligible. They didn’t have to go through as Mona said, some huge um eligibility uh thing, you know, filling out forms with maybe lots of intrusive questions. 

Dr. Mona Hanna-Attisha: That make you feel terrible about yourself. Like, I’m not good enough. 

Luke Shaefer: Right. 

Dr. Mona Hanna-Attisha: Something’s wrong with me. I can’t make it. I need help. 

Luke Shaefer: And that’s the other piece. Uh she hits the nail on the head, which is uh, the stigma. So when you when you have a means test like that, uh it sends a signal, right? You’re you’re giving a very different message to families that you can’t handle your business. So we’re here to, like, shore you up rather than um with RX kids. The message is, hey raising kids is hard, and everyone needs help, and uh we’re coming or walking alongside you and, um trying to do it from a place of love and support rather than, you know, a message that you’re not you’re not living up to the standard. 

Dr. Abdul EL-Sayed: Yeah. I really appreciate you all highlighting the stigma of means tested programs. Right. And when you tell people that this is only for you because you’re poor, you’re forcing people implicitly to admit a certain deficit to get access to this thing versus saying, actually, this is for everybody. And you look at Medicare, it’s fascinating. You know, there’s there’s always uh debates about Medicare, but they’re not serious. Everybody knows that, uh 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 they’re not ashamed to take Medicare dollars. They’re not ashamed to use Medicare or Medicare Advantage, not ashamed to collect on their Social Security. And so, you know, when you have, uh a united community around a particular policy, you’re right, that animosity goes away. The other part of it is, from a, um 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, uh monetary cost of having to hire a whole arm of bureaucracy intended specifically to create a, a bunch of barriers to getting the, the outcome of the policy. But then the other part of it is, is that there’s, there’s 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 waste in 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. 

Dr. Mona Hanna-Attisha: Yeah. 

Dr. Abdul EL-Sayed: To actually provide–

Dr. Mona Hanna-Attisha: Yeah. 

Dr. Abdul EL-Sayed: –people good things, rather than–

Dr. Mona Hanna-Attisha: Yup. 

Dr. Abdul EL-Sayed: –take them away or decide who gets them and who doesn’t? 

Dr. Mona Hanna-Attisha: Yep, yep. You see these uh conversations now with like universal school lunches and breakfast, which many states have adopted, including Michigan. It’s the same kind of message, like everybody needs it. 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. 

Dr. Abdul EL-Sayed: The other funny thing about it is um [laugh] is uh that this would be an inducement to have children that, you know, people are only having the kids to have to, to get the uh the benefit. And the funny thing about it is that, like, it’s very clear that the people who made up this argument never actually cared for kids. [laughter] Because like, nobody’s having extra kids to get $500 a month. That’s just not what you’re doing. That’s like not a not a thing somebody would do. Um. [laughing]

Luke Shaefer: Yeah. It’s uh, the international evidence is funny on this because actually a lot of countries adopted policies like this to try to increase their fertility rates. And in the United States, this is a real problem for us. I mean, the fertility rate is way down, and it’s going to continue to make it hard for us to pay for a lot of our programs, um because our because of population decline. Um. But time and time again, it has failed to increase the uh uh, the number of babies in a country. And um, you know, people have given up on that front in terms of the justification for this. 

Dr. Abdul EL-Sayed: Yeah. I mean it’s, that’s kind of a sad comment because I really wish that um, we could have more kids here because we we need them. And um, you know, if you look at the population pyramid, so, you know, just for listeners, I want you to imagine, a graph where, you know, on the on the vertical axis, you have the, like age groups, and in the y axis, you have the number of people in any age group. And if you think through where the US 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, uh but more so consumers, um that is, that is going to uh, 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. Um. Okay. Just wait and see what happens. See what happens when, you know, when we, we fail to reproduce. Um. And so, you know, to your point, like, we need to make it easier to have kids. And I think that’s the that’s the baseline. And it’s interesting, based on what you just shared, Luke, that it that policy alone doesn’t solve for the problem. But what’s really fascinating, though, is, you know, if you think about it, I think about my generation. So I’m about to turn 40 and um, 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 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, um 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 it’s also just the structure of our economic system that that we really need to be thinking a bit about. And this is a really important contribution in this respect. I want to um, I want to go back to something that you raised earlier, which is uh, the child tax credit. Right? That was for 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, what where do we think we stand in terms of being able to to bring that back, to be able to, you know, scale something, uh like the incredible program you talked about here, or RX kids in Flint to hit, you know, low income families in urban and rural communities all over the country?

Luke Shaefer: So um, the expanded child tax credit, had a few parts of it, which included the wonky term is making it fully refundable so that even families with very, very low earnings or no earnings would receive the full credit. And that had the biggest impact in really helping families at the very bottom. And uh, and then a second piece was making it a monthly credit. So it was again going very wo– wonkifying things. It was an advance, uh child tax credit that families received in 2021 based on their 2021 taxes. 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 at tax time. So I got to be a part of crafting that sort of structure um with a set of colleagues back in like 2016, 2017, after my um my book $2 a day. And at the time we wrote up a paper about it and uh, 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 uh 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 as what we had in 2021. So my hope is that they won’t become complacent. But um, you know, Mona and I spent a lot of time in Washington talking about RX kids and talking about um kid policy. And uh, 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 RX 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 um 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 a cash welfare program. It came out of the 1996 welfare law. But it turns out, um it’s really flexible money. And so states have really misused it. I think people, you know, really, pretty wide across the um, the political spectrum agree the program is not being used the way it should be. And so RX kids is historic in that um, the state of Michigan put TANF dollars towards this program, and that means that it’s something where there’s a, 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, uh red states and blue states, uh 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, um across a broader spectrum of the the political aisle. 

Dr. Abdul EL-Sayed: And uh Dr, Mona, I’ll give you the last word here. You know, if we were serious about building a kid safe and kid forward America, what are some of the other things that we would also be doing? 

Dr. Mona Hanna-Attisha: Oh Abdul, I love that question. So um, you know, we we talk about kids, we put them on a pedestal. We say they’re our future. But when you look at our policies, we really don’t care for children. I often have felt that we’re at war with our kids. Our child poverty rate is embarrassing, as we’ve talked about. It is an outlier in the world. Uh. We need to, you know, do things like the expand child tax credit and make it permanent. We need to do things like RX kids and make it permanent. Um. We need to tackle gun violence. It’s the number one killer of children is guns right now. Uh. We need to strengthen our environmental regulations so kids can breathe clean air and drink clean water. Uh. We need to raise the minimum wage so that, you know, families can support their children. Uh. You know, we we need parental leave policies, you know, also at par with other countries. Um. There’s a lot of things that we can do to protect the health and development of our children. Um. 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 um 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 and I’m really excited that we’re doing this on Valentine’s Day, because it’s also Frederick Douglass’s birthday. He is 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. Um. He said it is easier to build strong children than to repair broken men. Um. 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. Uh. That’s not how you build a community. You invest, uh especially for your, you know, respect the science of brain development in early childhood. You invest as as early as possible in kids. 

Dr. Abdul EL-Sayed: We really, really appreciate your leadership in in in bringing that to, to fruition in Flint through the RX kids program. Our guests today were uh Dr. Mona Hanna-Attisha and uh Professor Luke Shaefer. We really appreciate your leadership and and for coming on the show and sharing it with us. 

Dr. Mona Hanna-Attisha: Thank you. Abdul. It’s been a pleasure. And we can’t wait to share RX kids with the rest of the nation. 

Luke Shaefer: Really a treat. [music breka]

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. In his state of the Union speech last Thursday, President Biden called for an expansion of his Medicare drug price negotiation program. 

[clip of President Joe Biden] Americans pay more for prescription drugs than anywhere in the world. It’s wrong, and I am ending it. [cheers and applause]

Dr. Abdul El-Sayed, narrating: The current program will ultimately allow Medicare to negotiate drug prices for up to 20 prescription drugs per year. But under the new plan the president called for, he wants to expand that number to 50. Remember, the plan creates several protections for Big Pharma. Disallowing Medicare to negotiate for new drugs or drugs for which there are generics, for example. But that hasn’t stopped Big Pharma from trying to end the plan entirely. Fortunately for all of us, they’re losing. A federal court judge in Delaware recently rejected AstraZeneca’s argument that Medicare drug pricing 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. 

[clip of unspecified news reporter] Tonight, the highly infectious measles virus is spreading across more of the country, including in Florida, where a concerning outbreak is growing. 

Dr. Abdul El-Sayed, narrating: There have been dozens of cases of measles around the country, mostly from international travel. And 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. We’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 Elisabeth 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. 

[clip of unspecified news reporter] Breaking news overnight in the battle over IVF in Alabama, the governor signed a new law making it possible for fertility clinics to reopen. 

Dr. Abdul El-Sayed, narrating: The new law protects medical personnel from liability if they harm IVF embryos, in effect giving them the go ahead to resume operations, though it draws much more limited protections for others, like transfer companies, required in the health care system to provide this care. But the new law completely sidesteps the essential question at the heart of all this, whether or not IVF embryos are actual kids, which of course creates a glaring double standard in Alabama that creates a really weird precedent. That in the state of Alabama, yes, embryos are kids, but you won’t get in trouble if you kill them. 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 human hood 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-A D-I-S-S-E-C-T-E-D C-M-E.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 @CrookedMedia and me @abdulelsayed no dash on Instagram, TikTok and Twitter. Finally, I had the opportunity to do a cool interview with Melanie Sona and Erin Liedtke on their podcast Healthy Neighborhood, Healthy Nation. We talked about how we communicate science. I hope you’ll check it out. [music break] America Dissected is a product of Crooked media. Our producer is Austin Fisher, our associate producers are Tara Terpstra and Emma Illick-Frank. Charlotte Landes mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura.Our executive producers are Leo Duran, Sarah Geismer, and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice, and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests, and do not necessarily represent the views and opinions of Wayne County, Michigan or it’s Department of Health, Human and Veteran Services.