Lessons for Program Uptake: The 2024 Rx Kids Universal and Unconditional Cash Prescription Program in Flint, Michigan

Abstract

Programs in the United States aimed at improving maternal and infant health vary in effectiveness in reaching eligible participants. Administrative burdens such as learning, psychological, and compliance costs increase barriers to initial and sustained enrollment in these programs. This case study explored the effectiveness of Rx Kids—the United States’ first community-wide unconditional cash prescription program for mothers and infants launched in Flint, Michigan—in achieving exceptionally high program uptake. We compared total births among program participants with total births in Flint based on birth certificate records to estimate aggregate and prenatal uptake rates. We calculated an aggregate uptake rate in the range of 100% and a prenatal uptake rate of 93%. A limitation of our methodology was our inability to match program participants to birth certificate data. We discuss this and other limitations and offer recommendations for further refining estimates of program uptake using a data match process. The high uptake rate of Rx Kids underscores the importance of program design in reducing administrative burdens, with broad implications for improving maternal and infant health and public health at large.

The United States is exceptional among wealthy nations in its high child poverty rate, ¹ which peaks during the perinatal period due to declines in maternal income, the absence of paid parental leave, and the expenses of infancy. ² Economic insecurity during this neurodevelopmentally sensitive period can have lasting consequences.^3-5

Effective interventions can counteract perinatal poverty, improve maternal and infant health, and have lifelong positive effects. Yet, while some large-scale programs (eg, Medicaid/the Children’s Health Insurance Program) achieve high uptake rates (80%), most maternal and infant health programs are underused. ⁶ Only about 50% of eligible individuals use the Special Supplemental Nutrition Program for Women, Infants, and Children. ⁷ Temporary Assistance for Needy Families cash assistance and most state childcare subsidy programs serve <25% of eligible families, ⁸ and home visiting programs reach about 20% of eligible participants nationally.^9,10

Low program uptake has multiple drivers, including administrative hurdles, limited outreach efforts, confusing eligibility criteria, and program accessibility challenges.^11,12 The conditional and means-tested nature of most safety net programs creates barriers that affect people’s willingness and ability to navigate complex application and recertification processes. ¹³ These administrative burdens prevent program access and worsen health outcomes among socioeconomically disadvantaged populations.^11,14-16

The literature identifies 3 types of administrative burdens: learning costs, psychological costs, and compliance costs.^14,17 Learning costs refer to the time and effort expended to seek out program and eligibility information. ¹² These costs are high when program information is not readily available or is difficult to understand. ¹² Compliance costs refer to the time, effort, and other resources required to apply for, receive, and continue to receive benefits. ¹³ Complex screening procedures, excessive documentation requirements, and frequent mandatory in-person visits deter participation.^18,19 Lastly, psychological costs refer to emotional toll (eg, stress and frustration) stemming from accessing and maintaining program benefits and stigma related to participation. ¹⁷

Launched in January 2024 in Flint, Michigan, Rx Kids was designed to reduce administrative burden and was based on universal child cash transfer programs globally. ²⁰ It is the nation’s first community-wide prenatal and infant cash prescription program. Flint has a history of being a deeply disadvantaged city ²¹ with an extremely high child poverty rate (nearly 60%) ²² and poor maternal and infant health outcomes. ²³ Rx Kids is a place-based intervention designed to eliminate infant poverty and improve maternal and infant health. An academic–nonprofit partnership, Rx Kids is led by the Flint-based Michigan State University and Hurley Children’s Hospital–Pediatric Public Health Initiative in collaboration with Poverty Solutions at the University of Michigan and administered by GiveDirectly. The program was designed and implemented with input from key community partners, including parents and expectant mothers. Rx Kids leverages state Temporary Assistance for Needy Families block grant dollars and private philanthropic support.^24,25

Rx Kids prescribes $1500 to expectant mothers after 20 weeks of gestation and gives 12 monthly payments of $500 after birth. Available to all expectant mothers and infants in the city of Flint regardless of income, the program is unconditional and allows families to use the cash in a way that best meets their needs. Implicit in the design and reinforced in outreach, Rx Kids seeks to reimagine the social contract by conveying values of dignity, deservingness, trust, and love.

Purpose

This case study presents data on Rx Kids program participation and assesses aggregate program uptake using birth certificate data from the Michigan Department of Health and Human Services for the first 8 months of program operation. We discuss the role of the program’s design on its exceptionally high aggregate uptake rates while acknowledging limitations of this methodology and discussing approaches to refine these estimates using data match processes.

Methods

Program Design

We describe key features of the program designed to enhance uptake by mitigating 3 interrelated types of administrative burdens: reducing learning costs, minimizing psychological costs, and decreasing compliance costs (Table 1). ¹⁷

Table 1.

Three types of administrative burdens to program uptake and solutions to addressing these barriers in the Rx Kids program, Flint, Michigan, 2024 ^a

Participation barriers	Rx Kids solutions
Learning costs	• Simple eligibility requirements • Community-engaged outreach • Easy-to-navigate website and social media presence
Psychological costs	• Universal, unconditional, and predictable design • Celebratory messaging, special events • Focus on dignity, love, trust
Compliance costs	• Short electronic application • Minimal documentation requirements • Straightforward process to continue cash prescriptions after childbirth • Protection of other public benefits

^aThe Rx Kids program of Flint, Michigan, is a prenatal and infant cash prescription program that provides a $1500 cash payment to mothers during pregnancy and a $500 monthly cash payment for infants through 12 months of age. ²⁶

Reducing learning costs

Rx Kids has simple eligibility criteria: All expectant mothers or primary legal guardians of infants aged ≤6 months who live in the city of Flint at application may enroll. The program provides an unconditional cash benefit with no spending restrictions or behavioral requirements and no effect on most public assistance benefits. ²⁴ This simple design with clear eligibility criteria streamlines enrollment and keeps learning costs low.

Leveraging trusted partnerships, the program has communicated its eligibility criteria via community-engaged outreach efforts. Outreach materials, designed at a seventh-grade reading level, include rack cards and posters for display in obstetric and pediatric clinics and other locations serving pregnant women and infants. Marketing and outreach efforts are complemented by an easy-to-navigate, mobile-friendly website and social media promotion.

Minimizing psychological costs

Universal program eligibility reduces stigma and communicates dignity and deservingness, and unconditionality conveys trust, agency, and empowerment. Cash benefits are transferred into a participant’s bank account or a reloadable debit card.

Rx Kids uses branding, messaging, and special events to celebrate participants. All newborns born in Flint receive a personalized card with program information, Rx Kids–branded onesies, and a congratulatory welcome card from Michigan’s governor. Rx Kids also partners with local talent to create art, music, and celebratory events. ²⁷

All participants receive the same predictable prescription amounts. We posit that the program design contributes to a reimagined social contract ²⁸ that leads to restored hope and trust, thus increasing uptake.

Decreasing compliance costs

Rx Kids addresses compliance costs with an online application process that takes approximately 10 minutes to complete. Applicants answer questions that cover basic information, including birth date, full name, address, details about the pregnancy, and prompts to upload documents to verify identity, residency, pregnancy status, and/or birth status.

Identity verification mostly relies on a government-issued photo identification that includes full name, address, and birth date. Residency can be verified with a photo identification if issued within the last 6 months; however, applicants can use other items that show proof of address, such as a utility bill. Residency is verified only at enrollment. Acceptable documents to verify pregnancy include an after-visit summary from a medical provider or an ultrasound. Pregnancy documents must include maternal name, date of birth, and gestational age.

Submitting these documents is mobile-friendly and normally done when participants apply; however, it may take some applicants longer to upload documents. Rx Kids does not impose a time limit on verification documents. Those with incomplete applications receive reminders after 24 hours, 1 week, and then 1, 3, and 5 months.

After completing the application, participants are not required to attend in-person meetings. Instead, program administrators verify identity, residency, pregnancy status, and/or infancy status via submitted documentation. All applications are reviewed by trained staff members. Program integrity is maintained by using automated antifraud detection mechanisms to flag suspicious cases, which are then reviewed by staff.

After verification, applicants are informed of enrollment and begin receiving payments through direct deposit unless they have opted for a reloadable debit card. For debit card users, compliance costs are slightly higher because they must make an appointment to pick them up. Applicants can receive the prenatal $1500 prescription after 20 weeks of gestation and begin monthly infant payments after certifying birth. Applicants receive reminders to report a birth 4 weeks and 2 weeks prior to the due date and then again 2 and 4 weeks afterward. Compliance costs for birth certification are reduced by allowing participants to submit multiple types of documents, such as a state-issued birth certificate, hospital-issued certificate of live birth, infant vaccine administration record, or infant pediatric after-visit summary. Applicants who experience a miscarriage or loss receive bereavement payments.

Data and Analysis

We summarized sociodemographic characteristics of program participants who gave birth during the first 8 months of program operation (from January 1 through August 31, 2024). Because participants can enroll anytime from 20 weeks’ gestation to child’s age 6 months, we calculated program uptake only for those births whose period of eligible enrollment was closed to ensure comparative accuracy with state live births for the same reporting period. We determined the “aggregate” Rx Kids uptake rate for births in the city of Flint by dividing the aggregate number of births among participants enrolled in Rx Kids by provisional counts of aggregate live births geocoded for the city of Flint. Multiple births (ie, twins, triplets) were counted once, because the mother enrolled in the program only once. The birth certificate data are provisional, meaning that they are subject to change upon final review processes. The aggregate uptake rate methodology compared available program participation data with an estimated measure of the eligible population from administrative data to calculate a “crude” uptake rate. ¹⁰ With this methodology, it is possible to generate uptake rates that exceed 100% because participants must live in the city of Flint at the time of enrollment but may not live there at the time of birth. Individuals may apply prenatally and then move outside of Flint or move to Flint within 6 months after birth. In other words, some eligible families may not appear in Flint’s birth certificates because they are not living in Flint at the time of childbirth, leading to numerators greater than the denominator in estimated uptake rates. Uptake >100% may be due to residential mobility during pregnancy and the postpartum period, the broad window of eligibility, small differences in address geocoding, the use of provisional data, or error in conferring eligibility.

We calculated the prenatal uptake rate to assess the proportion of the uptake attributed to participants who enrolled prenatally. We calculated prenatal uptake as the number of births that occurred among program participants who enrolled prenatally (by infant’s birth month) divided by the total number of live births reported each month in Flint. Prenatal uptake is important because research finds that transfers delivered prenatally hold promise for improving maternal and infant health.^29,30

We assessed the effect of Rx Kids program outreach on uptake by examining the prevalence of self-reported responses to the application question “How did you hear about Rx Kids?”

The Rx Kids Prenatal and Infant Allowances in Flint program was deemed nonhuman subjects research by the Michigan State University (MSU) Institutional Review Board (STUDY00009891), and the Rx Kids Research and Evaluation study was approved for human subjects research by the MSU Institutional Review Board (STUDY00009177). MSU’s data use agreement with the Michigan Department of Health and Human Services to request research data from vital records on all live births in Michigan was deemed human subjects research exempt by the Michigan Department of Health and Human Services Institutional Review Board. Patient consent was not required because only deidentified program data were used to inform program uptake.

Outcomes

Characteristics of Rx Kids Program Participants

Most program participants who gave birth from January through August 2024 were pregnant at the time of application (662 of 776; 85.3%), and about half of applicants (n = 389; 50.1%) applied at 20 to 26 weeks of pregnancy (Table 2). Most participants (n = 485; 62.5%) were Black, 226 (29.1%) were White, and 65 (8.4%) were Hispanic. More than three-quarters of program participants (n = 610; 78.6%) were aged 20 to 34 years at enrollment. Nearly two-thirds reported annual household incomes of $0 to $10 000 (n = 358; 59.6%), and 23 (3.8%) participants had incomes ≥$50 000. While most participants chose direct deposit (n = 587; 75.6%), a greater proportion of young participants (aged <20 y) and those with lower incomes chose a debit card as compared with older participants and those with higher incomes, respectively.

Table 2.

Sociodemographic and program characteristics of mothers enrolled in the Rx Kids program who gave birth from January 1 through August 31, 2024, in Flint, Michigan (N = 776)

Characteristic	No. (%)
Pregnancy status at time of enrollment
Pregnant	662 (85.3)
20-26 wk	389 (50.1)
≥27 wk	273 (35.2)
Postpartum	114 (14.7)
Race
Black	485 (62.5)
White	226 (29.1)
>1 race	45 (5.8)
Other a	20 (2.6)
Hispanic ethnicity	65 (8.4)
Annual household income, $ b
0-10 000	358 (59.6)
10 000-20 000	83 (13.8)
20 000-30 000	79 (13.1)
30 000-40 000	39 (6.5)
40 000-50 000	19 (3.2)
≥50 000	23 (3.8)
Maternal age at enrollment, y
≤19	86 (11.1)
20-24	205 (26.4)
25-29	220 (28.4)
30-34	185 (23.8)
35-39	61 (7.9)
40-44	18 (2.3)
≥45	1 (0.1)
Disbursement method
Direct deposit	587 (75.6)
Prepaid debit card	189 (24.4)

^aIncludes American Indian, Native Hawaiian, and Asian.

^bA total of 175 participants did not report annual household income. Percentages were calculated by using the number of participants who reported income (n = 601).

Rx Kids Uptake Rate

A total of 776 infants enrolled in Rx Kids were born during the first 8 months of program operation (Table 3). Based on the aggregate number of births derived from state birth certificate records (n = 714), the overall uptake rate for Rx Kids was 109%, ranging from 95% in January to 128% in August, and the overall prenatal uptake rate was 93%. Unsurprisingly, considering that the program launched in January, births in that month had a larger proportion of postnatal enrollment compared with subsequent months, and prenatal enrollment was limited to those in their third trimester. As the program progressed, the percentage of prenatal enrollment increased, especially among those in their second trimester.

Table 3.

Prenatal and overall program uptake of Rx Kids for the first 8 birth months from January 1 through August 31, 2024, in Flint, Michigan (N = 776)

	Rx Kids program data, no. a				Program uptake rate, %
Birth month	Enrolled prenatally b	Enrolled postnatally	Total infants enrolled	Total live births from birth certificates, no. c	Prenatal	Overall
January	62	41	103	108	57	95
February	75	15	90	87	86	103
March	83	10	93	84	99	111
April	69	15	84	81	85	103
May	94	10	104	99	95	105
June	97	5	102	90	107	113
July	76	10	86	76	100	113
August	106	8	114	89	119	128
Total	662	114	776	714	93	109

^aProgram enrollment data include the number of births per month among mothers enrolled prenatally, the number of births per month among mothers enrolled postnatally, and the total number of enrolled infants by birth month.

^bPregnant women could not enroll to receive the prenatal cash payment until January 10, 2024.

^cEstimates of the count of live births in Flint are based on provisional state birth certificate data from the Michigan Department of Health and Human Services and are subject to change. Multiple births are counted once.

How Rx Kids Participants Learned About the Program

Self-reported data from enrolled participants showed that 41.8% of participants learned about Rx Kids from family, friends, or neighbors; 26.4% learned about it from social media; and 22.1% learned about it from traditional outreach, defined as rack cards and posters, information from program workers, billboards, and direct messages via text and email. Approximately 25% of respondents reported hearing about the program from >1 source.

Lessons Learned

In the first 8 months of operation, Rx Kids demonstrated an overall uptake rate in the range of 100% and a prenatal uptake of 93%. Most applicants enrolled prenatally (85.3%) and were informed of the program by friends and family. Compliance costs exert the strongest influence on program uptake ¹⁷ ; thus, reduced compliance obstacles have the greatest potential to improve uptake. Indeed, research on other public assistance programs demonstrated that reducing compliance costs improves participation. ¹⁷ In Rx Kids, the simple enrollment process with minimal documentation requirements and a mobile-friendly process keeps compliance costs low. In addition, benefits are easy to receive with more than three-quarters of participants electing direct deposit. Furthermore, the simple eligibility criteria, coupled with community outreach efforts, reduce learning costs by making the program easily accessible and understandable regardless of educational attainment or cognitive capacity.^11,31 Its universal and unconditional design minimizes psychological costs by reducing stigma and promoting a positive perception of the program in the community.

Our methodological approach to estimate program uptake followed standard conventions, but it may not have fully captured the true rate. The biggest challenge was the broad window of program enrollment and residential instability. Participants can enroll in Rx Kids between midpregnancy and 6 months of age; however, birth certificate data capture only self-reported address at birth. Residential mobility is highest among low-income families, with moving rates reaching as high as 32% during pregnancy.^32,33 Using independent data sources to derive the numerator (program data) and denominator (state birth certificate data) resulted in a numerator of births among Rx Kids participants that was higher than the denominator of eligible births reported in Flint. Similarly, Cunnyngham acknowledged that SNAP (Supplemental Nutrition Assistance Program) participation rates in some states can exceed 100% because of the differing sources of data used to estimate the numerator of participants and the denominator of the eligible population. ³⁴ For those states, rates were capped at 100%, with 95% CIs ranging from 92% to 100%. ³⁴

A future direction for more accurately estimating program uptake in the city of Flint could involve matching individual Rx Kids participants with birth certificate data to identify those enrolled in Rx Kids among the eligible population, which accounts for the broad window of eligibility and residential mobility. Furthermore, future plans to collect qualitative data on program participants’ experiences with application, enrollment, and verification processes will provide further insights into their perspectives.

Rx Kids is a timely and needed intervention that maximizes access to economic supports during the critical perinatal period. Sustained by public and private funding streams, the program has seamlessly expanded to several other urban and rural communities, with continued high uptake. ³⁵ The implementation success of this universal and unconditional program has implications for other underused governmental and nongovernmental programs intent on improving maternal–infant health outcomes.