Addressing the Social Determinants of Health in the Aftermath of COVID-19: Lessons From the 2008 Great Recession

In responding to the 2008 Great Recession, economists were split on whether to stimulate the world’s economies or proceed down a path of austerity in the face of mounting debts.¹ From differences in countries’ spending patterns, we learned that austerity may have caused not only poorer macroeconomic outcomes but also poorer health outcomes than prostimulus programs.² Antipoverty programs were particularly important for population health because low-income households suffered a disproportionate share of economic hardship and, therefore, a disproportionate burden of disease via the social determinants of health.³ These lessons from 2008, combined with recent research, can provide real-world guidance on social policy investments to optimize the health and economic well-being of low-income Americans in the aftermath of COVID-19.

COVID-19 AND INEQUALITY

Low-income workers are disproportionately more likely to be exposed to COVID-19 and succumb to it, with age being the primary risk factor for death from the virus. Toxic, poverty-associated stress, which is prevalent among low-income workers, leads to rapid biological aging relative to one’s chronological age,⁴ potentially explaining why low-income minority communities have mortality rates up to six times those of higher-income, predominantly White, communities.⁵ Low-income workers are also more likely to live in multigenerational households, potentially exposing vulnerable family members to illness and transforming social capital from an asset into a threat.⁶ These problems may be further compounded by recent upticks in evictions and food insecurity.⁷

As COVID-19 transitions from a health emergency to an endemic disease leaving a “K-shaped” recession in its wake, the Biden presidential administration is focusing on income support strategies such as child tax credits. We draw on social policy lessons from the 2008 Great Recession and recent research to explore whether this approach could mitigate mortality from both the ongoing COVID-19 pandemic and economic hardship.

EVIDENCE-BASED POLICYMAKING

Spikes in suicide and substance abuse were most pronounced in nations that responded to the Great Recession with austerity, making the need for social investment clear.³ However, social policies are not all created equal, as we see when weighing economic benefits and health impacts.⁸ For example, a multicenter randomized-controlled trial of welfare work requirements showed that although they improve the average person’s economic well-being, work requirements worsen population health⁹; those who cannot work are cut off from life-saving aid. Thus, it is crucial to ask which social policies will produce the greatest impact on both health and economic well-being. A recent review of social policies from the 1960s to the present provides data to support the results of cross-national studies of the 2008 Great Recession.⁸ These include research studies evaluating interventions in employment, income support, housing, and early life and education.

Employment Programs

The Great Recession and the COVID-19 recession both led to high unemployment, peaking at 10.0% and 14.7%, respectively.¹⁰ Many US welfare programs are conditional on employment, which is problematic when few jobs are available. As jobs return, novel methods must be developed to separate those who are able to work from those who are not—for example, because of caring for a large family or lacking access to transportation. A better means of identifying those who require Supplemental Security Income because of physical or mental disability is also needed. For example, much in the way that Google can predict individual characteristics with great accuracy, China’s Targeted Poverty Alleviation Campaign attempts to predict whether a low-income individual is in need of employment or cash assistance and then delivers the requisite intervention.¹¹

For those who can work, employment training can help. The randomized-controlled trial of JOBS II—a program that taught unemployed individuals at high risk for depression job-searching and problem-solving skills—found higher employment rates and fewer depressive symptoms after its two-year study period.¹² Job placement and training programs also offset increases in suicide during economic recessions.² Employment training can, then, be coupled with unemployment assistance, as more generous unemployment benefits were associated with improvements in overall health during the Great Recession.¹³

Income Supplementation and Protection

Income support and health insurance are associated with significant improvements in self-reported health.⁸ For example, the Paycheck Plus Program tested a fourfold increase in the Earned Income Tax Credit benefit in one multicenter randomized-controlled trial targeted at single adults without dependent children. Overall, the program produced small increases in employment, earnings, and tax credits—less than $1000 per year because relatively few participants responded to the incentives. Yet, these modest gains in earnings produced measurable improvements in health-related quality of life among those who responded to the program most vigorously: women and adults who were paying child support.¹⁴

Both the Great Recession and the COVID-19 recession also saw declines in health insurance coverage.^{15 , 16} At least 7.7 million people lost employer-sponsored insurance during the pandemic, a number that likely would have been higher had Medicaid been unavailable.¹⁶ Quasiexperimental studies suggest that Medicaid expansion saves lives,¹⁷ and randomized-controlled trial data suggest that it reduces clinical depression as measured by the Patient Health Questionnaire-9.¹⁸

Housing and Neighborhood Conditions

The Moving to Opportunity randomized-controlled trial provided rent vouchers to public housing residents to move into higher-income neighborhoods than those in which they were currently living. In theory, participants would be moved away from crime, food deserts, lead paint exposure, and many of the other health threats that tend to come with living in a low-income neighborhood. Physical and mental health benefits did appear, but only 10 to 15 years after randomization.¹⁹ Few other research studies have shown health benefits.

Early Life Interventions

Investments in schooling may benefit both children and parents. For children, they may address educational disparities that have been exacerbated by COVID-19–induced school closures, which threaten to erase decades of educational progress for underserved children. Although only two, small randomized-controlled trials have been conducted, the bulk of evidence suggests that education quality in early childhood may be the most important determinant of adult health.²⁰ For parents, prekindergarten programs provide a break from intensive parenting and an opportunity to enter the workforce. Given that US welfare programs focus on employed individuals, any program allowing parents to work could produce population health benefits. Once the acute COVID-19 crisis is managed, governments should, therefore, consider expanding access to early education programs. These programs also have the benefit of paying for themselves in the long run with both health and economic returns.²⁰

Families with older children at risk for dropping out of school may also benefit from education programs, as is demonstrated by the federal National Job Corps randomized-controlled trial.²¹ This program provided low-income youths aged 16 to 24 years educational and job training programs. Overall, the program produced increased receipt of a general equivalency diploma, vocational certificates, employment, earnings, and self-reported health. It also produced decreased involvement in the criminal justice system and modest reductions in the receipt of public assistance over the study’s four-year follow-up period.²¹

CONCLUSIONS

Lessons from the 2008 economic crisis and research on the health effects of social policies indicate that the Biden administration’s approach for COVID-19 relief will be effective at addressing both poverty and health disparities. Research suggests that cash assistance should be combined with Earned Income Tax Credit expansion, workforce training, and early education programs. However, for Earned Income Tax Credit expansion and workforce training programs to be effective, jobs must be available and accommodations must be made for those who cannot work.