Prescription for Cash? Cash Support to Low‐Income Families in Maternal and Pediatric Health Care Settings

Abstract

Policy Points.

• Pregnancy and childhood are periods of heightened economic vulnerability, but current policies for addressing health‐related social needs, including screening and referral programs, may be insufficient because of persistent gaps, incomplete follow‐up, administrative burden, and limited take‐up.

• To bridge gaps in the social safety net, direct provision of cash transfers to low‐income families experiencing health challenges during pregnancy, infancy, and early childhood could provide families with the flexibility and support to enable caregiving, increase access to health care, and improve health outcomes.

Experiences during pregnancy and childhood profoundly shape lifelong health and developmental trajectories, forming the uneven foundation for increasingly inequitable adult outcomes. ¹ , ² , ³ , ⁴ , ⁵ Although the importance of pregnancy and early childhood as critical periods is well understood, supports to families facing intersecting health and social needs are not well suited to the realities of this stage of life. In this article, we discuss the interplay between health and economic vulnerability during pregnancy and childhood, how these overlapping challenges are addressed by current policies, and discuss the rationale for cash transfers provided in health care settings, including examples of research from ongoing trials.

Maternal, infant, and child morbidity and mortality outcomes in the United States are consistently higher than other high‐income countries. ⁶ , ⁷ , ⁸ This pattern is driven by higher rates of adverse pregnancy and birth outcomes and worse child health outcomes for Black families and economically disadvantaged families. ⁹ , ¹⁰ , ¹¹ These disparities are increasingly understood to result from societal inequities, including structural racism and persistent child poverty not adequately addressed by the social safety net. ¹² , ¹³ , ¹⁴ , ¹⁵ Furthermore, adverse health experiences and complex health conditions during pregnancy and childhood put extraordinary pressure on already socioeconomically disadvantaged families, including increased visits to health care settings for monitoring and treatment, the potential for prolonged hospitalizations, and intensive caregiving demands. Meeting these demands can lead to increased economic precarity because of foregone income from missed hourly wages; increased out‐of‐pocket spending including transportation, parking, and accommodation costs incurred while utilizing health care; and the need to pay for food or childcare for other children. In turn, these economic burdens can make it more challenging for some families to participate actively in their care or the care of their children, contributing to disparities in outcomes.

Pregnancy and Childhood: A Period of Intense Economic Precarity

For low‐income families, pregnancy and childhood is a period of increased economic precarity. In 2021, 16% of children younger than 6 years of age were living in a household experiencing poverty, and 36% were living in a household with income less than 200% of the federal poverty line. ¹⁶ In 2022, the rate of child poverty doubled. ¹⁷ Because of structural racism and its impact on economic opportunities, ¹⁸ Black and Hispanic families are more likely to experience economic precarity. More than half of families experience an interruption in household employment during pregnancy and postpartum. ¹⁹ Approximately 30% of low‐income families pay more than 10% of their annual income on costs related to their delivery, with higher rates for families experiencing a preterm birth. ¹⁹ Some hospitals pursue aggressive debt collection policies, including charging those who should be receiving free care. ²⁰ The majority of low‐income mothers in the United States do not have access to paid family leave and report that they lose income when caring for a sick child. ²¹ , ²² , ²³ For families experiencing neonatal intensive care unit (NICU) hospitalization or child illness, this financial distress is even more pronounced. ²⁴ , ²⁵ With this backdrop of reduced income and increased expenses, families with children younger than 6 years old are more likely to experience threatened evictions, food insecurity, and energy disconnections compared with other populations. ²⁶ , ²⁷ , ²⁸ Increasing evidence suggests that persistent economic distress affects mental health ²⁹ and reduces the cognitive bandwidth available to focus on other priorities such as health challenges. ³⁰ , ³¹ , ³² Indeed, evidence suggests that low‐income families have lower rates of visitation in the NICU and lower rates of follow‐up care for a range of complex pediatric health conditions. ³³ , ³⁴ , ³⁵ , ³⁶

Addressing Social Needs in Health Care Settings: Current Approaches in the Obstetric and Pediatric Context and Their Limitations

Although high‐income countries around the world address economic precarity during pregnancy and childhood through substantial spending on the social safety net, the United States spends considerably more on health care compared with social support. ³⁷ , ³⁸ The United States health system, which increasingly recognizes that social determinants are associated with outcomes during pregnancy and early childhood, ³⁹ has begun to innovate around allocating health spending to address social inequities. ⁴⁰ One way that health spending is being reallocated to address social inequities is through screening programs that are increasingly common in obstetric and pediatric settings. ⁴¹ , ⁴² At least 24 states have explicit policies within their Medicaid programs that require screening for social needs. ⁴³ However, not all states that require screening mandate that families who are identified as having unmet needs be referred to existing programs. This means that families experience the alienation of sharing their challenges with their provider without their unmet needs being acknowledged or addressed. ⁴⁴ Qualitative reports from families suggest that screening can raise concerns about a lack of respect for dignity and autonomy, ⁴⁴ loss of confidentiality or potential harm, ⁴⁵ such as concerns that disclosure of economic deprivation may put families at risk of increased interaction with child protective services.

Ultimately, screening and referral programs are limited by the challenges of a fragmented and insufficient social safety net. ⁴¹ For many social needs, particularly housing‐related needs, ⁴⁵ referral options are inadequate. ⁴⁶ At a moment in which health systems have invested $2.5 billion dollars into programming related to addressing the social determinants of health (including investments in housing), there is concern that these efforts divert funds away from existing income supports that would reach families more directly. ⁴⁷ Health system efforts to rollout support for health‐related social needs have been hampered by substantial documentation burden ⁴⁵ and limited take‐up of referrals. ⁴⁸ , ⁴⁹ More recent evidence suggests that social determinants of health screening and referral, when performed with trained and trusted providers in an intensive setting, can substantial improve successful connection to referral. ⁵⁰ Nonetheless, even in this more intensive outreach programs, half of families identified as needing services do not access referral resources. ⁵⁰

Many eligible families do not apply for benefits from existing means‐tested, in‐kind, or income support programs, in part because of the complexity of application process. ⁵¹ , ⁵² , ⁵³ Families experiencing the dual burden of economic precarity and health challenges during pregnancy and childhood face extreme burdens on both their time and cognitive bandwidth. Families may be referred to a wide variety of federal and state income, housing, utility, and nutrition support programs. Navigating these programs can be challenging because of both the sheer number of programs and differences in design, eligibility, and application requirements. ⁵⁴ Navigation systems and in‐clinic supports, which help families access supports to which they are eligible, have been developed as part of health‐system–based interventions to address social needs. ⁵⁵ , ⁵⁶ , ⁵⁷ Although navigation systems may help families identify and apply to existing programs, these interventions require substantial inputs of family time and effort, do not always effectively accommodate families who are more comfortable communicating in a language that is not English, and may fail to reach families who have experienced health systems as historically untrustworthy. ⁵⁸ Furthermore, most mean‐tested programs are designed with strict income and resource limits, creating the risk of a “benefits cliff,” in which families may lose benefits eligibility once they are able to access additional resources or obtain higher paying jobs, yet the increased income fails to account for the total benefits lost. ⁵⁵

Another fundamental limitation of many existing supports is that they lack the flexibility needed by families experiencing both health complications and economic vulnerability, such as maintaining working hours while concurrently managing a complicated pregnancy or chronically ill child. The majority of programs provide in‐kind support, including the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and subsidized housing support, which can only be used for specific services. Programs such as Temporary Assistance for Needy Families (TANF) have seen the share of funds allocated to more flexible cash assistance for needy families sharply decline, and what limited cash assistance is available may still be dependent on adherence to specific work requirements, which may be impossible to fulfill for families experiencing health challenges during pregnancy and childhood. Moreover, programs that provide direct income supports may not be available for use at the time when they are most needed. For example, families may not receive Supplemental Security Income (SSI) benefits for a low birthweight infant until many months after their discharge, despite the economic strain faced by families during NICU hospitalization. ⁵⁹

Direct Cash Transfers: Consistent With Health System Values of Health Equity and Value‐Based Care

At a time when health care systems are increasingly embracing values related to improving equity in health outcomes and providing family‐centered care, extreme financial strain that prevents low‐income families from actively participating in care is a major obstacle to health care delivery consistent with these values. One potentially complementary approach to existing screening, navigation, and referral systems is the direct provision of cash transfers to low‐income families experiencing health challenges during pregnancy and childhood. Compared with existing programs, the receipt of cash transfers would require minimal engagement from already overburdened families in terms of their time or cognitive bandwidth, could be delivered at the time when they are most needed to enable participation in care and could be rolled out as a health insurance “benefit” provided to low‐income families experiencing specific health complications.

Evidence increasingly suggests that income supports have an impact on pregnancy and child health outcomes. ⁶⁰ Comprehensive evidence from low‐ and middle‐income countries suggests that cash transfers lower mortality for women and children younger than 5 years of age. ⁶¹ Quasi‐experimental studies of the Earned Income Tax Credit have shown improvements in birth outcomes when income support amounts increased. ⁶² An evaluation of the SSI program using a regression discontinuity found that infants receiving SSI have reduced rates of both acute and chronic conditions across childhood, ⁶³ though other evidence suggests that SSI payments during early childhood do not impact longer‐term outcomes. ⁶⁴ Direct support to families increased during the COVID‐19 pandemic with the expansion of unemployment insurance, the rollout of the Child Tax Credit, and increases to the Supplemental Nutritional Assistance Program. ⁶⁵ , ⁶⁶ Evidence suggests that the Child Tax Credit improved parents’ mental health and infants’ health and reduced emergency visits related to child abuse and neglect. ⁶⁷ , ⁶⁸ , ⁶⁹ However, many policies implemented during the pandemic are now ending despite their success in reducing poverty and improving health outcomes. More generally, public spending investments in children are less than 10% of the United States budget, whereas investments in adults through adult portions of Social Security, Medicare, and Medicaid are consistently over 30% of outlays ⁷⁰ despite the fact that investment in children will affect their lives over many decades.

Complex maternal and pediatric health conditions are both costly to health systems and incredibly challenging for families. Children with complex medical needs (e.g., prematurity, genetic, neurodevelopmental disorders, or cancer) experience frequent disease events and interactions with the health care system. Health care policy priorities and reform are highly salient to these populations for whom reform may significantly impact both child health and development and health care costs. Cash support to families experiencing these health challenges could be provided by the health care system as a “prescription” to enable caregiving activities at a time when economic precarity represents a significant barrier to health‐seeking behaviors. Although the health impacts of cash support during pregnancy and childhood have been documented in quasi‐experimental work, ⁷¹ they have not been evaluated in randomized trials in health care settings.

An ongoing trial of significant cash support to families of healthy full‐term infants (the Baby's First Years study) led to moderate reductions in poverty but limited evidence of improvements in maternal self‐reported stress or reports of children's sleep and nutrition. ⁷² , ⁷³ Results from the Baby's First Years study highlight the challenge of simple interventions to address the complex determinants of poverty, including long‐term financial stressors such as lack of stable and safe housing or employment. In addition to these persistent structural constraints, families experiencing health complications during pregnancy and early childhood also face increased short‐term financial burdens directly related to health care utilization, such as parking, transportation, childcare responsibilities for other children, and time off work. These burdens may acutely impede participation in evidence‐based caregiving and health seeking. Scalable, effective interventions that can temporarily alleviate short‐term financial burdens faced by low‐income families during critical health challenges—such as pregnancy or pediatric illness—are currently lacking. Although short‐term cash assistance to alleviate some of these acute financial stressors would not be expected to reduce childhood poverty, it could still represent a worthwhile intervention in the context of pregnancy or pediatric complex illness because of the critical, time‐sensitive nature of these periods for caregiving investments with lifelong health and development implications. Although the Baby's First Years study does not demonstrate that cash support improves parental mental health or other infant outcomes, there is evidence that parental time investments increased when parents were provided with cash transfers. ⁷⁴ For low‐income families facing complicated pregnancies and complex pediatric illness, the ability to spend more time to meet their extraordinary caregiving and health‐seeking demands could materially improve health outcomes.

Because the provision of cash transfers would represent a departure from typical health care practice, rigorous evidence is needed to quantify the impact of providing temporary cash support on families’ health‐seeking behaviors and related health outcomes. Two newly launched studies provide examples of how cash support could be rigorously evaluated within the interventional framework of a randomized controlled trial to improve health outcomes in pediatric care settings.

In the first study, socioeconomic disparities in the incidence of preterm birth ⁷⁵ and morbidity, mortality, and quality of care for preterm infants are persistent. ⁷⁶ , ⁷⁷ , ⁷⁸ Maternal presence in the NICU is increasingly recognized as a cornerstone to family‐centered care, as it is associated with improved maternal mental health outcomes (decreased stress and depression), infant growth, receipt of mother's breast milk, and skin‐to‐skin care; these factors are in turn associated with improved preterm infant health and development. ⁷⁹ , ⁸⁰ , ⁸¹ , ⁸² , ⁸³ , ⁸⁴ The NICU hospitalization for very preterm infants typically lasts weeks to months; however, consistent presence in the NICU is extremely challenging for low‐income mothers. ³³ Regularly visiting the NICU requires mothers to shoulder significant costs, including parking, childcare for other children, transportation, and accommodations while also forgoing income. A randomized control trial of financial support among 420 Medicaid‐eligible mothers with hospitalized preterm infants born at 24–33 weeks’ gestation will launch this year in four NICUs serving predominately Medicaid populations. ⁸⁵ Mothers in the intervention arm will receive standard of care enhanced with cash transfers of $160 provided each week for the duration of the NICU stay. The transfer amount was chosen to represent the maximum weekly food assistance (SNAP) benefits for a family of four. ⁸⁶ The scale of assistance provided in this pilot is not expected to come close to alleviating all of the short‐term financial stressors families face during an infant's hospitalization and cannot address challenges that will continue after discharge. However, the program may lessen the impact of these stressors on the families’ ability to participate in crucial maternal caregiving activities that require families to be present in the NICU.

Given the prevalence of preterm birth and the high likelihood of spending days to weeks in the NICU, temporary financial transfers provided within the high‐cost NICU environment have the potential to be cost saving if they can reduce the length of an NICU stay. The provision of breast milk to preterm infants has been shown to reduce morbidities that contribute to prolonged length of stay in the NICU. ⁸⁷ Moreover, when families are present more often in the NICU, they can participate in activities and trainings that facilitate timely discharge and may reduce length of stay. For an infant hospitalized over a 10‐week period, they would receive a total of $1,600. The median cost of a day of NICU care for infants younger than 32 weeks old was $3,045 in 2017. ⁸⁸ Therefore, if cash support enabled families to be marginally more prepared at hospital discharge, saving even one day of hospitalization, the cash support could be cost saving for the health system in addition to potential benefits to families and children in the short and long term.

Socioeconomic disparities in outcomes are similarly striking among children with cancer—another exemplar population of pediatric complex chronic illness with high health care utilization and costs and profound demands on families to support their children during intensive treatment. One in three US children with cancer lives in or near income poverty, ⁸⁹ , ⁹⁰ , ⁹¹ and poverty is an independent predictor of relapse and death across childhood cancers—including acute lymphoblastic leukemia, ⁹² , ⁹³ Hodgkin lymphoma, ⁹⁴ and neuroblastoma. ³⁶ Treatment for pediatric cancer is highly demanding, including the potential for more than 1 year of intensive, multimodal therapy—including chemotherapy, surgery, radiation, stem cell transplant, and immunotherapy—during which families incur profound costs secondary to work disruptions, travel, and parking to support their young children during months of inpatient hospitalization and intensive outpatient clinic visits.

A single‐center pilot study of direct financial support at a tertiary care center in Massachusetts enrolled ten families of children newly diagnosed with cancer and receiving at least 4 months of cancer directed therapy with an annual household income below 200% of the federal poverty level. Families received unrestricted cash transfers for 3 months—in a dollar amount based on the Child Tax Credit and number of household dependents ($600‐$1,000 per month). In follow‐up to this successful pilot, a two‐center, randomized feasibility study of identical financial support administered over 6 months at tertiary care centers in Massachusetts and New York will evaluate the feasibility of randomized cash transfers in this same population. The 6‐month duration of cash support is intended to span the most intensive period of chemotherapy for most childhood cancer diagnoses that are often associated with extended hospitalizations and frequent clinic visits for chemotherapy administration. This study will inform a subsequent randomized controlled efficacy trial to evaluate the hypotheses that unrestricted cash transfers will improve health care utilization as well as psychosocial and relapse outcomes in pediatric oncology. Similar to the NICU, the scale of assistance provided in this study will not alleviate the profound financial toxicity associated with childhood cancer treatment. Its goal is to help address basic resource needs—groceries, transportation, and rent—during the critical window of time when children initiate cancer therapy to facilitate the parental ability to be physically at the bedside and to adhere to highly complex medical regimens and restrictions at home.

Temporary cash transfers in pediatric oncology have the potential to be cost saving if they can reduce the length of a cancer hospitalization (median cost of a non‐ICU hospital day of care for a child with cancer is $3,900) or prevent a cancer relapse and subsequent intensive therapy (median inpatient hospitalization cost of intensive therapy after relapse can be as high as $406,195). ⁹⁵ Similar to the NICU population, parental presence at the bedside during childhood cancer hospitalization allows participation in complex discharge teaching (e.g., how to administer intravenous medications at home via an implanted central venous catheter) to facilitate timely discharge and reduce lengths of stay. Hospital discharge for children with cancer may also be delayed by concerns around stable housing or family ability to access reliable transportation to return for outpatient chemotherapy clinic visits as frequently as two to three times per week. Finally, temporary cash transfers may facilitate improved adherence by supporting copays for oral cancer medications and/or increasing parental cognitive bandwidth to focus on administration of complex medication regimens at home.

These ongoing studies are informed by evidence that cash transfer programs are best designed as an unconditional benefit with predictable and regular disbursements that are delivered via debit card. ⁹⁶ , ⁹⁷ Furthermore, these programs do not require families to apply for cash support given the ordeals that low‐income families experiencing health challenges during pregnancy and childhood are already facing. ⁹⁸ Beyond these general principles, however, there are many important questions about the optimal amount, frequency, and duration of transfers given budgetary and political constraints that need to be explored. Given the extensive financial burdens that families face while caring for children during an NICU stay or complex pediatric illness and the high cost of these types of care, future research could consider the efficacy of even larger transfer amounts that more fully account for the financial burdens of caregiving, such as lost income as well as childcare for other children. Future research could also consider expanding pilots to include families whose income does not qualify them for Medicaid but who may face crushing and unexpected out‐of‐pocket costs from high deductible health care plans. ¹⁹ Cash transfers delivered to families in health care settings are best conceptualized as a complement to the existing constellation of public benefit programs and specific hospital and community initiatives. For this reason, financial support might be expected to have different impacts for families across different starting points of income and economic precarity and across different states, which differ substantially in the implementation and organization of their safety net programs (i.e., parental leave programs, TANF, SNAP, Medicaid, etc.).

The provision of cash transfers during pregnancy and pediatric complex chronic illness such as cancer may provide the flexibility and support to enable families to participate in caregiving during a critical moment for determining morbidity and mortality outcomes as well as spending by the health system. Beyond these benefits, it also may improve the feeling of dignity that families experience in their interactions with the health care system. In the current system, both families and providers experience significant hospital‐based spending at a time when families’ inability to manage economic precarity can prevent them from being part of their own children's care or ensuring their child participates in the state‐of‐the‐art services provided by the health care system. For example, in the NICU, insurers will routinely pay for each ounce of donor breast milk (approximately $4.50 per ounce) and the cost of shipping because of its strong link to gut infections that drive mortality ⁹⁹ but do not provide any financial support to a low‐income mother with her own breastfeeding goals to pump around the clock and transport expressed milk to the NICU. In some cases, parents experiencing economic challenges who are perceived to be insufficiently attentive to their children's medical needs may be referred to child protective services and lose custody of their ill child. ¹⁰⁰ If cash transfers can increase the perception that maternal and pediatric health care delivery systems understand the economic strain that affect families’ participation in caregiving, this would be a small step toward rebuilding trust in the health care system. ¹⁰¹

Challenges to the Implementation of Cash Transfers Within Health Systems

Although cash transfers have tremendous potential for impact in maternal and pediatric settings, including as a way of benchmarking the effectiveness of programs that provide connection to referral services, ¹⁰² there are several barriers to their implementation. First, Medicaid is limited by law in its ability to use funds on nonhealth expenditures. Although state Medicaid programs have increasingly turned to Section 1115 Demonstration Waivers to address social determinants of health, ¹⁰³ these waivers must demonstrate budget neutrality and often lack implementation flexibility. ¹⁰⁴ Additional flexibilities through Medicaid Managed Care, including “in lieu of services,” have also expanded pathways to address health‐related social needs. ¹⁰⁵ However, interventions through these innovative flexibilities have, so far, been limited to in‐kind supports. The provision of direct cash support, which provides a flexibility and timeliness that may be critical during the peripartum and childhood period, might require further policy guidance from Medicaid.

Second, direct cash transfers may affect families’ eligibility for other benefit programs in which eligibility is determined by assessing household income (including SSI, SNAP, WIC, TANF, subsidized housing support, and Medicaid). If cash transfers provided during peripartum or childhood make families ineligible for other benefit programs, they may perversely increase economic precarity. Researchers and policymakers working to study guaranteed basic income programs have pursued a number of avenues to mitigate these risks, including advocacy for waivers that would exempt cash transfers from income calculations for public benefits eligibility ¹⁰⁶ and benefits counseling in which such exceptions are impossible. ¹⁰⁷ Integration of cash support during pregnancy and early childhood into Medicaid or private insurance benefits would need to carefully consider the potential impacts on other social program eligibility.

Finally, the incorporation of flexible cash‐based support to families may face political barriers to implementation in the United States. When compared in surveys, in‐kind payments (such as those for food or housing) are more popular compared with direct cash transfers. ¹⁰⁸ Evidence suggests that opposition to policies that redistribute financial resources stems at least in part from racial biases. ¹⁰⁹ , ¹¹⁰ Policymakers have often voiced concerns that flexible cash payments might be spent on things like alcohol or smoking ¹¹¹ despite evidence from rigorous trials studying the effects of cash transfers demonstrating that such spending is rare. ¹¹² , ¹¹³

Conclusion

Families facing the layered challenges of economic precarity and managing health shocks during pregnancy and childhood may benefit from the flexibility and timeliness of temporary cash support. This kind of flexible financial support may enable health care utilization and caregiving that are critical for improving maternal and child outcomes, providing a value‐based rationale for implementation by insurers or other payers. Evidence from randomized controlled trials is needed to inform the impact of cash support during these critical periods and address potential political challenges to their implementation. Furthermore, policy innovation is needed to address potential barriers to the implementation of cash‐based benefits.

Funding/Support: McConnell and Parker gratefully acknowledge support from the NICHD: R01HD109293. Bona gratefully acknowledges support from the American Cancer Society and the Children's Cancer Research Fund.

Conflict of Interest Disclosures: No disclosures were reported.