Financial Coaching Offers New Paths To A Healthy Future

‘A Tale Of Two Cities’

As a safety-net hospital, Boston Medical Center is well acquainted with hardship, as encountered by its patients, their communities, and the hospital itself. Founded during the Civil War as Boston City Hospital, the first municipal hospital in the US, it was located in an area that then seemed far south of the city center.¹

“The hospital was located in a somewhat insanitary portion of the city, but considerations of economy and expediency prevailed at that time and have prevented a change of location,” one history noted.¹ Immediately, the hospital began treating emergencies and infectious diseases, caring for the city’s poor, mostly Irish, immigrants.²

Today the hospital’s backdrop is a bit more complicated, as seen from the expansive windows of the sixth-floor pediatric clinic in the Yawkey Ambulatory Care Center. To the north the city’s tallest buildings rise from the affluent Back Bay neighborhood: the sleek, triangular One Dalton (luxury condominiums and the Four Seasons Hotel), the iconic Prudential Tower, and 200 Clarendon (formerly known as the John Hancock Tower). The opposing view faces Roxbury, the neighborhood just south of the hospital at the heart of African American Boston. From this height it isn’t possible to know that among the nearby modest red-brick row houses, one offers emergency housing for women fleeing domestic violence, and another is a homeless shelter.

Pediatrician Megan Sandel points to this view as a “tale of two cities.” The hospital also borders Boston’s South End, which is “historically working class, now fully gentrified with multimillion-dollar apartments,” says Sandel, codirector of the Grow Clinic, which treats infants and children with a diagnosis of failure to thrive and a national expert on how housing affects child health. Massachusetts Avenue, which bisects the medical campus, has typically served as a dividing line between prosperity and adversity, she says.

At ground level it’s even easier to see the precarious nature of life here, so close to both the business hub of Boston and the nexus of the city’s opioid epidemic. In January 2022 the city removed a huge tent encampment at the edge of the Boston Medical Center campus near the corner of Massachusetts Avenue and Melnea Cass Boulevard, known colloquially as “Mass. and Cass.” The mayor later said that 200 people were relocated to housing; dozens ended up at a temporarily shuttered round red-brick hotel just steps away.³

Police lights still flicker night and day in the area, as officers keep a watchful but lenient eye on an open-air drug market down the street. Hospital employees receive alerts on their cellphones about intersections to avoid if there is more-urgent police activity.

The center of Roxbury, known as Nubian Square, is only about a mile from the hospital. Although the neighborhood is focused on revitalization—many buildings are emblazoned with bold murals, and vacant lots have been reclaimed for new businesses, pocket parks, or housing—it seeks to avoid the gentrification that would make the area unaffordable for longtime residents. Fears of displacement are layered onto worries about the encroaching opioid epidemic and the stresses of poverty; structural racism; rising housing costs; and, for some, complicated immigration status.

Boston Medical Center, which took its current name when Boston City Hospital merged with Boston University Medical Center Hospital in 1996, faces its own stressors. In three of the five years spanning 2016–20, the health system recorded operating losses.⁴ Three out of four of its patients are publicly insured, which equates to low reimbursements for care.⁵ Although cultural diversity is a strength in the community, it is also a challenge—for example, hospital interpreters provide on-site assistance in the fourteen most commonly spoken languages.

The hospital has long embraced a mission beyond delivering health care.

The hospital has long embraced a mission beyond delivering health care. For example, it stocks a food pantry in the basement and recently invested its community benefit funds in affordable housing in Roxbury. Reach Out and Read, an early literacy program now found at 6,100 pediatric care sites around the country, began at what was then Boston City Hospital in 1989. In 1993 Boston Medical Center created the first medical-legal partnership, now a national initiative, engaging legal professionals to help resolve patients’ social needs such as threatened evictions or substandard housing. Boston Medical Center funds its special programs through philanthropy and grants, which includes a $5 million JPMorgan Chase grant that the hospital received to form the Boston Opportunity System Collaborative, a partnership with other hospitals, nonprofit organizations, and the city of Boston to provide job training and affordable housing.

“Let’s think in a more expansive way,” says Bob Vinci, chief of pediatrics, explaining the paradigm. “‘Social determinants of health’ is an identifier, and antipoverty medicine is a response.”

‘Wealth Is Health’

In 2014 the system’s focus on advocacy attracted Michael Hole to a special health equity track in the pediatric residency program that Boston Medical Center runs with Boston Children’s Hospital. During an internship with the American Academy of Pediatrics (AAP) during medical school, he had learned about the impact of the EITC, which currently provides up to $6,164 for low-income families with two children.⁶ Families that have earned income but owe little or no taxes can receive their credit as a refund, giving them an infusion of money.

Hole began asking his patients whether they had filed taxes and received the credit (each year, an estimated 22 percent of eligible people nationally do not receive it),⁷ and he gave them information about the Boston Tax Help Coalition and its Internal Revenue Service (IRS)–sponsored Volunteer Income Tax Assistance centers, where they could get free help.

One mother of a newborn was grateful for the information. She had been paying hundreds of dollars to for-profit tax firms. But on her next visit she had a tale of frustration. She had taken two buses and a subway to the center, only to find that it was closed. She returned during its limited office hours, only to learn that she didn’t have the necessary documentation. At that point, she gave up and spent the money at a for-profit tax preparer.

“I waited on you for twenty or thirty minutes in your waiting room,” the mother told Hole at her baby’s next well visit. “Wouldn’t it be great if we could do my taxes here?” Hole thought she had a good point: The pediatric clinic was already linking patients to resources, so adding voluntary tax assistance didn’t seem like a stretch.

He drafted a memo and shared his idea with Marcil, at the time a first-year pediatric resident in the same track, who had spent time in the Peace Corps working on financial empowerment with women in Namibia. Together they went to Vinci, the chief of pediatrics, suggesting a space in the clinic’s reception area. They compared the program to a medical-legal partnership, but for financial help.

Vinci’s response: Sure, why not? “I had no idea what we were getting into and whether it would take off, but it was the kind of idea that was creative, that would bring a resource to our families that didn’t exist, and it would take advantage of health care being a respected part of the life of a family,” Vinci says. Parents were already coming frequently to the pediatric clinic, and they already had a trusted relationship with physicians and staff. In the sixth-floor reception area, four-foot-high metal replicas of children’s books could block off cubbies for privacy.

Still, there were some issues to sort out. The hospital’s lawyers worried about the potential liability of asking patients to disclose financial information. Hole and Marcil gave them a presentation, explaining the existing IRS-sponsored training for volunteers and the predicaments many patients faced in accessing help. Eventually, hospital officials gave their OK.

One of the tax assistance program’s first clients was a fifty-five-year-old grandmother who earned $7,000 annually working part time while taking care of her three-year-old grandson. She previously had paid $400 for tax help to get her $2,400 credit refund; now she didn’t have to pay a third-party fee to secure a refund, which left her with extra money to splurge on fresh produce, new winter blankets, and items for her grandson.⁸

Because of delays in setting up the program, StreetCred began in mid-February 2016, after many low-income parents had already filed their taxes, wanting to get their refunds as soon as possible. Even so, in its first season StreetCred served 186 families and helped them receive more than $400,000 in tax credits.² To date, the program has helped more than 4,000 clients receive more than $9 million.⁸

“Our goal is to put more money in people’s pockets because it turns out wealth is health,” says Hole, who is now an assistant professor of pediatrics, population health, and public policy at the University of Texas at Austin and founder and executive director of the Impact Factory, a hub for entrepreneurship that has launched and scaled several innovative organizations, similar to StreetCred, that seek to combat social problems. He is board chair of StreetCred.

‘It’s Not Hopeless’

The health toll of poverty has many dimensions: stress, depression, poor diet, obstacles to accessing preventive care, exposure to neighborhood violence or high rates of pollution. But it can be summed up by a single set of numbers. Near the Nubian Square hub of Roxbury (census tract 817), the average life expectancy at birth is seventy-three years,⁹ and 24 percent of children live below the national poverty level.¹⁰ About two miles to the north, in the Back Bay neighborhood (census tract 106), no children live in poverty, 86 percent of adults have a college degree,¹¹ the average owner-occupied unit costs $1.5 million, and the average life expectancy is eighty-eight—fifteen years longer than in Roxbury.⁹

Pediatricians at Boston Medical Center see the effects of poverty on the youngest Bostonians.

Pediatricians at Boston Medical Center see the effects of poverty on the youngest Bostonians. Soukaina Adolphe, a pediatrician and codirector of the Grow Clinic, comes to work some days carrying canvas bags filled with containers of specialty formula for babies who can’t tolerate the standard version. The formula is expensive, so families sometimes dilute it to make it last, not realizing that they are putting their baby at risk for malnutrition, Adolphe says.

A national formula shortage in mid-2022 made matters worse, and even months after the shortage began to subside, specialty formula remained difficult or impossible to find in poor neighborhoods. Adolphe and some of her team members called stores in the city or region and sometimes traveled to towns hours away from Boston, looking for the special formulations. That’s a strategy available to well-off Bostonians facing the same shortage, but not to families with limited means and no transportation, she says.

“The longer [a baby] is malnourished over time, it takes a toll on cognition,” she explains. “The more we are able to correct it, we can change their trajectory. We’re getting a large number of babies referred to Grow because they were on the verge of being malnourished.”

Poverty shapes childhood in ways that are both obvious and insidious. Families regularly come to the emergency department because they have no place else to go. They don’t need health care; they need housing. Eileen Costello, Boston Medical Center’s chief of ambulatory pediatrics, recalls treating a baby with a diaper rash. She happened to go to the restroom after the visit and encountered the mother, who was washing her child’s disposable diaper in the sink.

Even with screening forms for social determinants of health, patients are sometimes reluctant to share their financial straits, Costello learned. “I ran and got her diapers and told her, ‘We can help,’” she recalls. “She didn’t know.”

Children are more likely to live in poverty in the US than people in any other age group. Forty-four percent of children experience episodic poverty (living below the poverty level for at least two consecutive months)—a rate that is almost three times higher than that for adults ages sixty-five and older, the Census Bureau found in an analysis of data from the period 2013–16.¹² In 2020 about one in six children, or 16.1 percent, lived below the poverty level, which is $26,246 for a family of two adults and two children.¹³

Ten years ago, when Benard Dreyer, professor of pediatrics at NYU Grossman School of Medicine, in New York City, served as president of the Academic Pediatric Association, he delivered a presidential address to fellow academic pediatricians and other stakeholders. His speech focused on child poverty, which he called a “national disgrace.” He urged academic pediatric health professionals to make reducing child poverty in the US “our greatest priority advocacy activity.” He noted that child poverty is associated with low birthweight, higher rates of chronic diseases such as asthma, and poorer social and emotional development, among other health-related problems.¹⁴

Resolving child poverty might seem like a quixotic aim, like ending world hunger or achieving world peace. “One of the goals of my speech was to create an agenda and say it’s not hopeless,” Dreyer says. “There are many things we can all do and that we can all advocate for.” Pediatricians welcomed the encouragement, as well as the recommendations. “It was an amazingly positive response,” he recalls.

In 2016 Dreyer became president of the AAP, which represents all pediatricians, not just those in academic settings. Under his leadership the AAP issued a policy statement on “Poverty and Child Health in the United States,” urging pediatricians to screen for risk factors related to social determinants of health, refer patients to appropriate community resources and programs, and advocate for policies that support children in poor and low-income families.¹⁵

“Just a few screening questions opens the eyes of health care providers to the needs of those children,” says Benjamin Gitterman, a pediatrician in Silver Spring, Maryland, who then headed the AAP’s Council on Community Pediatrics and a workgroup on child poverty that drafted the AAP statement. He notes that electronic medical record systems increasingly prompt pediatricians to ask about social risk factors such as unstable housing.

Dreyer also served on a National Academies of Sciences, Engineering, and Medicine panel convened by congressional request, which recommended evidence-based programs with the aim of cutting child poverty in half within ten years. The committee included experts in child health, development, and welfare; economics; social policy; and disparities. In a 2019 report the committee began by outlining the extent of child poverty and its impact: “We find overwhelming evidence from this literature that, on average, a child growing up in a family whose income is below the poverty line experiences worse outcomes than a child from a wealthier family in virtually every dimension, from physical and mental health, to educational attainment and labor market success, to risky behaviors and delinquency.”¹⁶

The committee concluded that the EITC and Child Tax Credit are the most powerful tools to reduce child poverty, followed by the Supplemental Nutrition Assistance Program (SNAP, or food stamps).¹⁶ The National Academies “road map” influenced President Joe Biden and congressional Democrats as they crafted a 2021 pandemic relief package—the American Rescue Plan Act expanded SNAP, the EITC, and the Child Tax Credit. From July to December 2021 families were able to receive monthly advance payments based on an annual refundable credit of $3,600 per child younger than age six and $3,000 for children ages 6–17. Some 1.8 million fewer children were in poverty during those six months because of the Child Tax Credit—a 23 percent reduction in the child poverty rate compared to the expected rate without the benefit, according to an analysis by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services and the Urban Institute.¹⁷ However, the Biden administration failed to get congressional approval to extend the enhanced tax credits.

With the enhanced Child Tax Credit, “we found that families were better able to afford food, catch up on rent, and parents reported better health outcomes,” says Allison Bovell-Ammon, director of policy strategy for Children’s Health Watch, a national nonprofit advocacy and research organization based at Boston Medical Center. “We also found that families were less stressed when they got the payments.”

The effects might be even more profound. Baby’s First Years, a unique multicenter study examining how monthly cash payments affect early brain development, began in 2018. One thousand low-income mothers of newborns were randomly assigned to receive either $333 per month ($4,000 per year) or $20 per month ($240 per year) on a debit card.¹⁸

Although the pandemic derailed in-person data collection from March 2020 to mid-2022, first-year electroencephalography results from 435 babies showed higher-frequency (more fast-paced) brain activity in babies of mothers receiving the higher cash amounts—a sign of brain development associated with thinking and learning. Because the two groups studied were similar, as measured on twenty-seven characteristics at baseline, researchers can conclude that the higher payments led to the differences in brain development, says Kimberly Noble, a pediatrician and neuroscientist at Columbia University, in New York City, who is the study’s lead principal investigator for neuroscience.¹⁸

“We were very excited by this early result,” says Noble, who cautioned that follow-up electroencephalograms will show whether the differences continue as the children get older.

Noble notes that prior studies already show an association between income support and health outcomes—the “wealth is health” paradigm. “Social determinants are a key aspect of health care, especially pediatric health care,” she says. “Anything that we as pediatricians can do to optimize access to programs and services for people with low income is likely to benefit children’s health and well-being.”

‘A Bigger Focal Point’

Extra money helps relieve the day-to-day stress on families, but achieving financial mobility is a deeper goal. As StreetCred evolved, it sought to help patients not just with their finances but also with financial literacy.

Barbara Alcena grew up in Haiti, a place where many people lack the tools of personal finance, such as credit cards. She immigrated to Florida, got a degree in social work, and spent the next seven years visiting homes there, and later in Massachusetts, to protect children in situations of child neglect, abuse, and abandonment. There she saw the role of severe financial stress in the family dynamic.

So Alcena understands why many patients at Boston Medical Center have issues with money. “You don’t have a population here that necessarily comes from generations of understanding finances, or maybe finance was introduced to them in a very traumatic way,” she says. “How we all look at money is different. How we manage money is different. We’re finding it has a lot to do with how people are raised.”

Alcena came to Boston Medical Center to coordinate a program called Project REACH, which brought pediatric care into the community during the height of the pandemic. She then joined Boston Medical Center’s Center for the Urban Child and Healthy Family, where she learned about financial coaching and broadened her work with families, also becoming a part of StreetCred.

Alcena takes a trauma-informed approach to her work with StreetCred and in the financial mobility program for the Pediatric Practice of the Future, an innovative model created by the Center for the Urban Child and Healthy Family. In interviews conducted by outside specialists in human-centered design, parents said that an ideal practice would include financial wellness. In addition to the one-on-one coaching, about ten families will join group sessions, learning to become peer coaches for other families. (The model also includes “community wellness advocates,” who help patients define the goals of their medical visits.)

“It’s really to empower those families to make [financial] decisions on their own and pass [the skills] on to their children,” Alcena says.

Of course, Medicaid doesn’t have a billable code for financial healing. Beyond private funding—the Pediatric Practice of the Future is supported by the JPB Foundation in New York—Boston Medical Center hopes that ultimately, better health outcomes will produce cost savings. The hospital has a large Medicaid accountable care organization.

Boston Medical Center is sharing lessons from its focus on asset building and financial mobility with other hospitals around the country.

Boston Medical Center is also sharing lessons from its focus on asset building and financial mobility with other hospitals around the country. For example, the Healthy Neighborhoods Healthy Families initiative at Nationwide Children’s Hospital in Columbus, Ohio, has long sought to address social determinants of health. After learning about StreetCred, Nationwide Children’s added tax clinics to help patients receive their full EITC. Recently, the hospital launched a pilot version of a matched savings program. Thirty families will receive a dollar-for-dollar match up to $5,000 for money they save over the course of eighteen months, as well as financial coaching and mentoring to help them learn budgeting skills.

“We’ve always been a housing-first initiative, but these financial services are starting to become a bigger focal point for us,” says Nick Jones, vice president for community wellness at Nationwide Children’s.

The tax clinics helped set the stage for broader work on financial mobility, Jones says. But nationally, antipoverty medicine is still an emerging concept. “I don’t think people realize how much opportunity they have to be a part of this,” at every level of a health system, says Boston Medical Center’s James. “They’re busy thinking that’s somebody else’s lane.”

Antipoverty medicine unfolds in the shadow of the “war on poverty” of the 1960s, which created a safety net and reduced poverty but failed to end it, in part because those crafting the changes failed to fully comprehend or grapple with the deep-seated and systemic injustice that is so tightly interwoven with persistent poverty. Today the pediatric clinic at Boston Medical Center functions with a clear understanding of how profoundly health is connected to financial stability. Its health teams encounter the challenges of poverty every day, and this is a chronic ill they are determined to address.

“People say you can’t cure poverty. Well, why not?” says pediatrician Sandel. “What are we doing if we don’t try to cure poverty? It is an entrenched multidimensional problem that requires an all-of-system response.”

NOTES

• 1 A history of the Boston City Hospital, from its foundation until 1904. JAMA. 1907;48(7):635. Google Scholar
• 2 Hole MK, Marcil LE, Vinci RJ. Improving access to evidence-based antipoverty government programs in the United States: a novel primary care initiative. JAMA Pediatr. 2017;171(3):211–2. Crossref, Medline, Google Scholar
• 3 Becker D. Boston mayor announces plan to prevent another tent encampment at “Mass. and Cass.” WBUR [serial on the Internet]. 2022 May 24 [cited 2022 Sep 23]. Available from: https://www.wbur.org/news/2022/05/24/wu-boston-homelessness-drug-crisis-plan Google Scholar
• 4 Center for Health Information and Analysis. Acute hospital financial performance trends [Internet]. Boston (MA): CHIA; 2021 Sep [cited 2022 Sep 23]. Available from: https://www.chiamass.gov/assets/Uploads/mass-hospital-financials/2020-annual-report/five-year-trend/bmc.pdf Google Scholar
• 5 Center for Health Information and Analysis. Boston Medical Center: 2020 hospital profile [Internet]. Boston (MA): CHIA; 2022 Apr [cited 2022 Sep 23]. Available from: https://www.chiamass.gov/assets/docs/r/hospital-profiles/2020/bmc.pdf Google Scholar
• 6 Internal Revenue Service. Earned Income and Earned Income Tax Credit (EITC) tables [Internet]. Washington (DC): IRS; [last updated 2022 Aug 30; cited 2022 Sep 23]. Available from: https://www.irs.gov/credits-deductions/individuals/earned-income-tax-credit/earned-income-and-earned-income-tax-credit-eitc-tables Google Scholar
• 7 Anderson N, Athreya K, Keller J, McCord R. ProfitWise news and views: why are millions of dollars in tax refunds going unclaimed? [Internet]. Chicago (IL): Federal Reserve Bank of Chicago; 2022 Mar [cited 2022 Sep 23]. Available from: https://www.chicagofed.org/publications/profitwise-news-and-views/2022/millions-tax-refunds-unclaimed Google Scholar
• 8 Boston Medical Center. StreetCred [Internet]. Boston (MA): Boston Medical Center; 2022 [cited 2022 Sep 23]. Available from: https://www.bmc.org/streetcred Google Scholar
• 9 National Center for Health Statistics. Life expectancy at birth for U.S. states and census tracts, 2010–2015 [Internet]. Hyattsville (MD): NCHS; 2018 [cited 2022 Sep 28]. Available via query from: https://www.cdc.gov/nchs/data-visualization/life-expectancy/ Google Scholar
• 10 Census Reporter. American Community Survey 5-year estimates: census tract 817, Suffolk, MA [Internet]. Washington (DC): Census Bureau; 2020 [cited 2022 Sep 23]. Available from: https://censusreporter.org/profiles/14000US25025081700-census-tract-817-suffolk-ma/ Google Scholar
• 11 Census Reporter. American Community Survey 5-year estimates: census tract 106, Suffolk, MA [Internet]. Washington (DC): Census Bureau; 2020 [cited 2022 Sep 23]. Available from: https://censusreporter.org/profiles/14000US25025010600-census-tract-106-suffolk-ma/ Google Scholar
• 12 Mohanty A. Dynamics of economic well-being: poverty, 2013–2016 [Internet]. Washington (DC): Census Bureau; 2021 Aug [cited 2022 Sep 23]. (Report No. P70BR-172). Available from: https://www.census.gov/content/dam/Census/library/publications/2021/demo/p70br-172.pdf Google Scholar
• 13 Shrider EA, Kollar M, Chen F, Semega J. Income and poverty in the United States: 2020 [Internet]. Washington (DC): Census Bureau; 2021 Sep 14 [cited 2022 Sep 23]. (Report No. P60-273). Available from: https://www.census.gov/library/publications/2021/demo/p60-273.html Google Scholar
• 14 Dreyer BP. To create a better world for children and families: the case for ending childhood poverty. Acad Pediatr. 2013;13(2):83–90. Crossref, Medline, Google Scholar
• 15 Gitterman BA, Flanagan PJ, Cotton WH, Dilley KJ, Duffee JH, Green AEet al. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339. Google Scholar
• 16 Duncan G, Le Menestrel S, editors. A roadmap to reducing child poverty [Internet]. Washington (DC): National Academies Press; 2019 [cited 2022 Sep 23]. Available from: https://nap.nationalacademies.org/catalog/25246/a-roadmap-to-reducing-child-poverty Google Scholar
• 17 Macartney S, Ghertner R, Wheaton L, Giannarelli L. Federal economic stimulus projected to cut poverty in 2021, though poverty may rise as benefits expire [Internet]. Washington (DC): Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2022 Feb [cited 2022 Sep 23]. Available from: https://aspe.hhs.gov/sites/default/files/documents/452493535752b7b9e60f7406d6a40a7b/poverty-projections-2021-2022-rb.pdf Google Scholar
• 18 Troller-Renfree SV, Costanzo MA, Duncan GJ, Magnuson K, Gennetian LA, Yoshikawa Het al. The impact of a poverty reduction intervention on infant brain activity. Proc Natl Acad Sci U S A. 2022;119(5):e2115649119. Crossref, Medline, Google Scholar