Child Poverty and Health in the United States: Introduction and Executive Summary.

Abstract

Poverty cuts lives short and strips livelihoods bare. It is linked to increased risk to countless dimensions of child health and development, it disrupts medical care that could address those risks, and it carries these health harms into adulthood and across generations.1Schickedanz A Dreyer BP Halfon N Childhood poverty: understanding and preventing the adverse impacts of a most-prevalent risk to pediatric health and well-being.Pediatr Clin North Am. 2015; 62: 1111-1135https://doi.org/10.1016/j.pcl.2015.05.008Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar No group is more vulnerable to falling into poverty in the United States than children, whose health and development are exquisitely sensitive to the adverse effects of being poor. Roughly 1 in 5 children lives in poverty as the United States has defined it since the 1960s using the antiquated Federal Poverty Level. Fully 2 in 5 American children live in households that are considered low income at less than twice the Federal Poverty Level, a threshold which better hews to the international standard poverty cutoffs used in other developed countries. By any measure, the United States—the wealthiest country on Earth—has for decades maintained among the worst rates of child poverty of nations in the industrialized world. This issue has been brought into stark relief during the coronavirus disease 2019 pandemic, throughout which families with children have disproportionately borne the economic brunt of a once-in-a-lifetime plague. These historic challenges have created opportunities for policy progress, such as the implementation of a child allowance, just when many families’ budgets needed it most. But for how long will the window of opportunity for policy progress remain open? What roles will pediatricians play in their practices and communities to protect children and families from poverty and its lifelong health effects? How can we better understand the nature and experience of poverty to take more effective action to prevent it and mitigate its adverse effects? The conditions of poverty are about much more than dollars and cents, or the simple lack thereof. The existence of poverty is only possible if abided by a social indifference, ignorance, or outright callousness that allows the indignity and existential distress of scarcity to persist. That our society tolerates this violent indifference to the lived experience of millions of impoverished children remains a profound failure and abdication of our most fundamental responsibility to future generations. It does not have to be this way. Pediatricians (and many others) know this,2Dreyer BP To create a better world for children and families: the case for ending childhood poverty.Acad Pediatr. 2013; 13: 83-90Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar which is why in 2012 the Academic Pediatric Association (APA) founded a Task Force on Childhood Poverty to organize experts from across disciplines ready to tackle poverty as a pervasive threat to child health. The APA Task Force brought together leaders from the APA and the American Academy of Pediatrics, and both organizations adopted poverty and child health as strategic priority areas for policy and advocacy. The Task Force outlined a roadmap that focused its strengths in clinical care delivery, education, research, policy, and evidence-based advocacy on the issue of child poverty and health. Central to this road map to address child poverty was a state-of-the-art compilation of evidence and interventions to inform antipoverty solutions and to light the way forward—this was the first Academic Pediatrics Child Poverty Supplement funded through the support of the Robert Wood Johnson Foundation.3Dreyer B Chung PJ Szilagyi P et al.Child poverty in the United States today: introduction and executive summary.Acad Pediatr. 2016; 16: S1-S5Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Since then, the work that started in 2012 with the APA and American Academy of Pediatrics strategic priority of reducing child poverty has involved countless pediatricians and others who refuse to be indifferent to the health impact of child poverty. This work is ongoing and has only grown, evolved, and taken on new dimension and urgency. Much has changed since the first Academic Pediatrics Child Poverty Supplement published in 2016, and so this second Child Poverty Supplement is expanded in scope and reach to reflect advances in the science and knowledge essential to pediatricians and anyone else concerned with the health and well-being of children in the United States. This Supplement moves beyond how poverty is numerically defined to understand how it is socially constructed. It includes evidence on progress in our understanding of poverty's prevalence and health risks, presents solutions to treat child poverty at various levels from policy to clinical practice, and approaches the topic of poverty from an intersectional lens, recognizing that poverty operates as a principal mechanism of structural racism and systematic social marginalization. The current Supplement, made possible thanks again to the generous support of the Robert Wood Johnson Foundation, brings together leading clinicians, scholars, educators, economists, public health experts, policymakers, and community advocates to inform readers on key poverty-related themes around which the issue is organized, including:•Equity, or lack thereof, in the unequal distribution of poverty and its consequent health risks patterned by social disadvantage and exposure to racism,•Effective antipoverty state and Federal policies•Clinical and health system responses to poverty•Community-wide antipoverty and health interventions In this executive summary, we briefly present main ideas and conclusions from each of the articles, organized by section of the Supplement. In addition, we highlight the Supplement's commentaries on health care policy as a tool to reduce child poverty (Drs Sharfstein and Thornton4Sharfstein J Thornton RLJ US healthcare policy and child poverty.Acad Pediatr. 2021; 21: S88-S89Abstract Full Text Full Text PDF Scopus (1) Google Scholar), the decades-long journey of a policy that will cut child poverty in half this year (and hopefully in years to come as well) as told by the lawmaker who shepherded it from fringe proposal to a signature on the president's desk (Congresswoman Rosa DeLauro5DeLauro RL Why we need a permanent expanded and improved child tax credit.Acad Pediatr. 2021; 21: S90-S91Abstract Full Text Full Text PDF Scopus (2) Google Scholar), a re-affirmation of American Academy of Pediatrics’ commitment to child poverty reduction and the pillars of its antipoverty policy and advocacy priorities (Drs Beers, Szilagyi, Goza, Seigel, and Mark Del Monte, JD6Beers LS Szilagyi MA Goza SH et al.Ending child poverty by investing in children and families.Acad Pediatr. 2021; 21: S92-S93Google Scholar), and a meditation from 3 pediatrician leaders of the Robert Wood Johnson Foundation (Drs Besser, Morita, and Schwarz7Besser R Morita J Schwarz D We know how to fight poverty. So let's fight.Acad Pediatr. 2021; 21: S86-S87Abstract Full Text Full Text PDF Scopus (1) Google Scholar) on a future in which our nation's over-half-century-old War on Poverty is won—but only if we finally choose to “fight” with gloves off. Two articles comprise the first section and frame the urgency and opportunity to reduce child poverty in the United States. Dr Mona Hanna-Attisha and co-authors8Hanna-Attisha M O'Connell L Reyes G et al.The American promise.Acad Pediatr. 2021; 21: S94-S96Google Scholar tell the story of how the community of Flint, Michigan, and its children were poisoned with lead in the drinking water through the confluence of poverty, racism, financial exploitation, political disempowerment, and environmental injustice. Through the microcosm of Flint, they share lessons for anyone concerned with how to overcome the toxic harms of poverty with collective community action, including efforts by pediatricians to treat children and affect the social and economic conditions that shape health. Dr Greg Duncan9Duncan G A roadmap to reducing child poverty.Acad Pediatr. 2021; 21: S97-S101Google Scholar summarizes the causal evidence demonstrating child poverty's health harms and presents policy recommendations issued by the National Academies of Sciences, Engineering, and Medicine's consensus Committee on Building an Agenda to Reduce the Number of Children in Poverty by Half in 10 Years. The paper emphasizes that a bundled antipoverty approach can both reduce child poverty and increase parental employment at the same time, and it highlights the tremendous impact of the child allowance. The conclusions serve as a roadmap for reducing child poverty substantially in the United States through policies and programs, some already enacted, including strategies that successfully avoid political and economic barriers that have hamstrung decades of prior proposals. This section discusses how social and economic marginalization have been structured to coincide in communities disproportionately afflicted by child poverty in the United States, with implications for health equity and health care beginning in the earliest stages of the life course. Drs Kendra Liljenquist and Tumaini Coker10Liljenquist K Coker T Transforming Well-Child Care to Meet the Needs of Families at the Intersection of Racism and Poverty.Acad Pediatr. 2021; 21: S102-S107Abstract Full Text Full Text PDF Scopus (2) Google Scholar begin the section examining how pediatric health care and the medical home can counter structural racism through focus on programs tailored to serving children and communities facing the intersection of racism and poverty. They review the history of the medical home and propose an improvement framework to reshape it through antiracist re-conceptualization of pediatric preventive care. The paper offers a repository of structural clinical improvements and innovative programs to buffer the health and developmental risks of child poverty. Going beyond health care, Dr Nia Heard-Garris and co-authors11Heard-Garris N Boyd R Kan K et al.Structuring poverty: how racism shapes child poverty and child and adolescent health.Acad Pediatr. 2021; 21: S108-S116Abstract Full Text Full Text PDF Scopus (7) Google Scholar unpack the relationships between structural racism, poverty, and population health through a comprehensive, expansively interdisciplinary evidence synthesis. They arrive at a conceptual model to explain how centuries of systematic economic and political oppression and predatory racial capitalism have resulted in health inequities in Black, Native American, Alaskan Natives and Latinx children, families, and communities. The authors outline areas for antipoverty solutions in domains such as economic reparations, decarceration with support, equitable educational funding, and environmental justice, all of which address racial inequities in the distribution of resources and power where children live, learn, and play to improve health outcomes and eliminate disparities. Dr Dolores Acevedo-Garcia and co-authors12Acevedo-Garcia D Joshi PK Ruskin E et al.Including children in immigrant families in policy approaches to reduce child poverty.Acad Pediatr. 2021; 21: S117-S125Abstract Full Text Full Text PDF Scopus (1) Google Scholar focus on children in immigrant families in the United States, who are at substantial increased risk of poverty and its health consequences due to overt eligibility restrictions on major antipoverty programs, burdensome administrative complexity that outstrips the navigational capital of linguistically marginalized families, and fear of the consequences of uptake of safety net programs in the wake of the (now dropped) Public Charge rule. The article reviews the stark disparities in poverty rates by family immigration status and presents estimates of the impact of promising policy approaches to poverty reduction for children in immigrant families. It concludes with a series of policy principles to reduce eligibility and administrative hurdles that imperil their economic and physical health. Drs Bettenhausen, Winterer, and Colvin13Bettenhausen JL Winterer CM Colvin J Health and poverty of rural children: an under-researched and under-resourced vulnerable population.Acad Pediatr. 2021; 21: S126-S133Abstract Full Text Full Text PDF Scopus (1) Google Scholar draw connections between the economic, geographic, and health and health care disadvantages facing the 1 in 5 children who live in rural areas in the United States. They propose a set of solutions to the unique challenges posed by rural child poverty, as well as a research agenda to build evidence on what works to mitigate the health impacts of the unique economic hardships and social conditions rural children face. This agenda involves prioritizing specific policies that particularly affect rural children, and studying factors contributing to rural poverty and strategies to reverse these factors. Drs Empey, Garcia, and Bell14Empey A Garcia A Bell S American Indian/Alaska Native child health and poverty.Acad Pediatr. 2021; 21: S134-S139Abstract Full Text Full Text PDF Scopus (1) Google Scholar make the case that the alarming rate of child poverty in American Indian and Alaska Native communities—roughly 1 in 3—can only fully be understood in context of centuries of land and resource dispossession, cultural loss, intergenerational cycles of adversity, and structural and physical violence. They describe how economic oppression and health deprivation wrought by racist policies were both consequences and drivers of historical trauma. Solutions proposed include (but are not limited to) increases in funding for the Indian Health Service, equitable education policies, and foregrounding programs run by and centering American Indian and Alaska Native communities themselves. The article further concludes that ending rapacious policies is insufficient to reverse the economic and health damage done to generations of Native American children without the restoration and re-appropriation of cultural practices and tribal sovereignty. Two articles update and synthesize what is known about the development and impact of key antipoverty policies at the state and Federal levels in the next section of the Supplement. Drs Curran, Garfinkel, and Wimer15Curran MA Garfinkel I Wimer C The evolution and impact of Federal antipoverty programs for children.Acad Pediatr. 2021; 21: S140-S145Abstract Full Text Full Text PDF Scopus (2) Google Scholar trace the history and evolution of the social safety net of Federal antipoverty programs for children in the United States to explain its uneven impact and structural shortcomings today, shortcomings further exacerbated by the coronavirus disease 2019 pandemic. The authors offer a comprehensive look at our nation's progress toward more effective poverty-reduction policies, revealing the substantial opportunity for lasting improvements in child poverty rates afforded by promising program advances, such as permanently establishing the child allowance and moving toward greater universalism by expanding programmatic coverage for children who have historically fallen through the safety net in the United States. Drs Janet Currie and Anna Chorniy16Currie J Corniy Medicaid and CHIP improve child health and reduce poverty but face threats.Acad Pediatr. 2021; 21: S146-S153Abstract Full Text Full Text PDF Scopus (1) Google Scholar summarize the latest evidence on the benefits to child health and economic security of policies expanding Medicaid eligibility and access for pregnant women and children, including a number of recent studies demonstrating the substantial long run impacts of Medicaid and the Children's Health Insurance Program. Yet despite the stronger-than-ever evidentiary support for Medicaid expansion, public insurance rates for children have recently eroded, largely through deliberately burdensome administrative barriers to coverage at the state level. With rates of uninsured children now rising rapidly, the authors issue a clarion call to restore and further expand Medicaid, to make the Children's Health Insurance Program permanent, eliminate lockouts or waiting periods, increase Medicaid reimbursement to parity with private payers, and continue many components of the CARES Act, such as implementing a permanent counter-cyclical federal match rate. The next section turns to the role of pediatricians and the health system more broadly in directly treating poverty itself, addressing its consequent social risks, and mitigating its adverse health impacts. Drs Garg, Brochier, Messmer, and Fiori17Garg A Brochier A Messmer E et al.Clinical approaches to reducing material hardship due to poverty: social risks/needs identification and interventions.Acad Pediatr. 2021; 21: S154-S160Abstract Full Text Full Text PDF Scopus (3) Google Scholar explore the burgeoning paradigm shift in pediatrics—and health care more broadly—toward clinical interventions that mitigate poverty-related material hardships and social risks. The authors provide an overview of these “upstream” care models and assess their strengths and limitations based on the available evidence. They propose promising directions for research and practice in this growing area of health care innovation with the potential to reshape poverty and child health in the United States. Specifically, the authors highlight the opportunities for this growing field to build evidence through practical research designs for robust evaluation in real world settings, study longer-term impacts, and explore implementation contexts and strategies that lead to successful, sustainable clinical innovation and practice transformation through which clinical encounters can better address adverse social risks for patients, families, and communities. Dr Rachel Gross and co-authors18Gross RS Messito MJ Klass P et al.Integrating health care strategies to prevent poverty-related disparities in development and growth: addressing core outcomes of early childhood.Acad Pediatr. 2021; 21: S161-S168Abstract Full Text Full Text PDF Scopus (1) Google Scholar draw parallels between child development and physical growth (ie, weight status) insofar as they are both linked to poverty and may, therefore, have common causal pathways that can form the basis for an integrated approach to addressing both in concert. The common thread linking poverty-related outcomes of developmental delay and obesity, the authors posit, is disruption of relational health, specifically through poverty/scarcity-related barriers to the quality and consistency of parent-child interactions that form a stable and responsive foundation for attachment and the parent-child relationship upon which healthy child growth and development depend. They review evidence on the spillover effects of programs that have separately targeted growth or development into the reciprocal domain, suggesting that these programs are actually operating on a common pathway. The authors propose an integrated framework for conceptualizing how early relational health impacts child health and development and, in so doing, make the case for integrating interventions for prevention of problems in child development and growth in the pediatric setting. Dr Lucy Marcil and colleagues19Marcil LE Hole MK Jackson J et al.Anti-poverty medicine through medical-financial partnerships: a new approach to child poverty.Acad Pediatr. 2021; 21: S169-S176Abstract Full Text Full Text PDF Scopus (2) Google Scholar describe the emerging field of antipoverty medicine that targets poverty and financial stress directly for treatment as a health intervention by clinicians, practices, and health care systems. They compile insights from Medical-Financial Partnerships—collaborations between health care and financial services to improve health by reducing financial hardship—nationally, make the case for growth of these cross-sector service delivery models based on the existing evidence, and offer a guide for clinicians interested in establishing their own antipoverty Medical-Financial Partnership programs. Dr Melissa Klein and co-authors20Klein M Hanson E Lichtenstein C et al.Poverty related education in pediatrics: Current state, gaps and call to action.Acad Pediatr. 2021; 21: S177-S183Abstract Full Text Full Text PDF Scopus (2) Google Scholar assess the state of antipoverty education in pediatrics, revisiting a major area of emphasis of the APA's 2016 Task Force. They expand the framework for poverty-related pediatric education to include the central role of racism and important opportunities to partner with families and communities with lived experience of poverty, while also providing a logic model for outcomes and a vision for how poverty-related training can progress throughout the medical education continuum. They urge the development and expansion of faculty development programs to build a pipeline of antipoverty medical educators, and they propose curricular evaluation strategies that assess metrics far beyond learner knowledge and attitudes, such as patient outcomes. They call for an expanded medical educator workforce to combat child poverty with the support of pediatricians and their professional organizations. The final section of the Supplement expands the frame to poverty reduction and child health promotion at the community level, where pediatricians have opportunities to play a greater role in cross-sector partnerships capable of improving population health and equity. Drs Jutte, Badruzzaman, and Thomas-Squance21Jutte DP Badruzzaman RA Thomas-Squance R Neighborhood poverty and child health: Investing in communities to improve childhood opportunity and well-being.Acad Pediatr. 2021; 21: S184-S193Abstract Full Text Full Text PDF Scopus (2) Google Scholar introduce community economic development as a powerful vehicle for poverty alleviation and health improvement at the neighborhood level that remains largely unknown to pediatricians and unexplored by health care. The authors orient the reader to the community development field and provide examples of how the health and vitality of communities have been transformed through neighborhood-level investment. They conclude with recommendations to pediatricians for how to successfully engage, advise, evaluate, and advocate for communities within this ripe area of multisector innovation. Ms Green, Ms Bovell-Ammon, and Dr Sandel22Green KA Bovell-Ammon A Sandel M Housing and neighborhoods as root causes of child poverty.Acad Pediatr. 2021; 21: S194-S199Abstract Full Text Full Text PDF Scopus (2) Google Scholar review how housing and housing policy profoundly shape child and family health. They summarize major turning points in the history of housing policy in the United States, drawing connections to their implications for poverty and community health. The authors conclude by summarizing solutions to improve housing equity at various levels, from individual patient- to practice- to institution- to policy-level interventions. Dr Andrew Beck and co-authors23Beck AF Marcil LE Klein MD et al.Pediatricians contributing to poverty reduction through clinical-community partnership and collective action: a narrative review.Acad Pediatr. 2021; 21: S200-S206Abstract Full Text Full Text PDF Scopus (1) Google Scholar articulate the importance of multi-lateral, cross-sector collaborations for achieving progress toward economic and population health equity. The article provides a roadmap for pediatricians to contribute to and accelerate collective action through clinical-community partnership development, highlighting cross-sector approaches to poverty reduction and health promotion. They summarize examples of successful clinical and health system approaches. The authors offer a vision of system transformation for poverty reduction through networked learning and collective action. In sum, the expert voices that compose this second Academic Pediatrics Poverty Supplement represent a chorus calling for action, based in abundant evidence, to end child poverty and protect the health, development, and opportunity that should be afforded every child to reach their full potential. Pediatricians are in a unique and influential position to help poor and socially-marginalized children by joining this chorus through action in their practices, communities, and through public discourse and policy advocacy. But in order for this call to end child poverty to have an impact, it needs to lead to change beyond the pages of this Supplement—that part is up to you. What will you do? What will each of us do? What will we do collectively to prevent another child's life from being cut short by poverty in the richest nation on Earth? Now's the time to turn evidence into action against child poverty. Our nation's children cannot wait. We acknowledge the support of the Robert Wood Johnson Foundation for making this supplement possible. Financial disclosure: The authors have no financial relationships relevant to this article to disclose. Dr Schickedanz's time during the creation of this supplement was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (award 1K23HD099308 ) and he received research support from the Health Resources and Services Administration of the U.S. Department of Health and Human Services (award UA6MC32492 ). Drs Schickedanz and Szilagyi received funding from NIH / NCATS grant number UL1TR00188 . The information, content, and/or conclusions of this article are those of the authors. This article is published as part of a supplement sponsored by the Robert Wood Johnson Foundation.