Are cash benefits for families associated with positive childhood experiences?

In the U.S., state and federal governments employ vast bureaucracies that aim to ensure that only the "deserving" receive public assistance in the form of subsidized health care, food, and housing. 2025 has seen a near-complete reversal of the pandemic policy of keeping people on Medicaid by default; now, states will be required to not only confirm Medicaid eligibility every 6 months, but to verify that certain "able bodied" beneficiaries are enrolled in job training or working at least 80 hours per month. Never mind that Medicaid is only a health care benefit - you can't use it to pay the rent or feed your family - or that work requirements have been unequivocal failures in states that have tried implementing them in the past. The point of this cruel policy isn't to increase employment; it's to save money by removing people from health insurance rolls even if they are working.

What are the effects of financial insecurity on child health? A systematic review in AJPM Focus found that "financial strain was associated with poorer health and well-being and more behavior challenges among children of all ages, poorer academic performance among school-age children, and more depressive symptoms among adolescents." Adverse childhood experiences (ACEs) such as child neglect, abuse, and exposure to violence affect at least one in four American children and are associated with unhealthy behaviors and chronic diseases in adults. As one might expect, these experiences occur more often in neighborhoods with built-in disadvantages such as high concentrations of poverty, pollution, limited green-space, and poor access to healthy food sources. A medical approach to this problem would be to screen patients for ACEs and provide some sort of intervention to counteract the negative effects of childhood trauma. It's unclear if such an approach actually helps, though, and even if it does, the public health professional in me thinks there must be better ways to prevent ACEs in the first place.

A recent cross-sectional study in 4 states (Kansas, Montana, South Carolina, and Wisconsin) turned the concept of ACEs on its head and instead asked more than 20,000 adults if they had experienced one or more of the following positive childhood experiences (PCEs):

1. Adult made you feel safe and protected

2. Felt you belonged in high school

3. Felt supported by friends

4. At least 2 adults took an interest in you

5. Felt your family stood by you

6. Enjoyed community traditions

7. Felt able to talk to your family

Adults who reported higher numbers of PCEs were more likely to have attended postsecondary school, had greater household incomes, were less likely to smoke, and had fewer chronic medical conditions than those reporting lower numbers. So how can our society reduce exposure to ACEs and increase exposure to PCEs? An analysis in the Milbank Quarterly illustrated that state policies that improve economic security are associated with better mental health outcomes in children and adults. More bureaucracies, then? Hardly. Arguably the most effective social policy implemented during the pandemic was the temporary 2021 expansion of the Child Tax Credit, which effectively provided "a near universal, unconditional child cash benefit," reducing child poverty to historically low levels.

Closer to home, since 2022 Philadelphia has experimented with providing no-strings attached cash assistance to low-income families rather than making them wait for inadequate public housing or limited numbers of vouchers to become available. Families (households had to have at least one child under the age of 16) fortunate enough to receive monthly payments ranging from $15 to $2057 (with a median of $1000) have generally applied them toward rent. Not only were households who received cash less likely to be evicted or become homeless, they also had fewer concerns about the quality of their housing.

I attended a conference recently where a presenter half-facetiously, half-seriously, summed up all of the risk factors for developing a chronic health condition as "Don't Be Poor." Our historic societal response to poverty has been to create difficult-to-navigate welfare programs with ever-changing eligibility requirements that help poor people with health care and food and housing but basically force them to stay poor to keep receiving benefits. What if we cut through the red tape and just gave them cash instead? Would fewer ACEs and more PCEs occur, leading to better health for everyone in the long run? It's not the kind of research that the National Institutes for Health will fund any time soon - they're too busy trying to prove that vaccines cause autism - but it's definitely a question worth studying.

Courage and consequences at the CDC

In a recent presentation to preventive medicine residents at Johns Hopkins, I reflected on the painful circumstances that led to my resignation from the Agency for Healthcare Research and Quality (AHRQ) in November 2010. In short, political decision-makers well above my pay grade attempted to protect Democratic congressional majorities from blowback from an anticipated recommendation against prostate cancer screening by forcing the U.S. Preventive Services Task Force to cancel a scheduled meeting. Until this year, when Health and Human Services Secretary Robert F. Kennedy, Jr. cancelled the USPSTF's July meeting and expressed his intent to replace the entire panel, it was arguably the worst example in the Task Force's history of politics trumping science. (This time is worse - a LOT worse.)

Last week, the HHS Secretary fired recently confirmed Centers for Disease Control and Prevention (CDC) Director Susan Monarez over her unwillingness to “to rubber stamp [vaccine] recommendations that flew in the face of science.” In protest, three senior CDC officials simultaneously resigned. On his Inside Medicine Substack, Dr. Jeremy Faust posted the full text of the e-mails that Dr. Deb Houry, Dr. Demetre Daskalakis, and Dr. Daniel Jernigan sent to their colleagues announcing their respective resignations. Without question, these three doctors were far more critical to the day-to-day work of the CDC and HHS than I ever was or might have been at AHRQ. But their collective departure, like mine nearly 15 years ago, raises an important question: when a public servant who is also a health care professional witnesses the federal government taking immoral or profoundly troubling actions, is it more courageous to step down (and draw attention to how these actions endanger health) or to remain in place and continue to resist from the inside, hoping that eventually new leadership will restore the primacy of science and evidence-based medicine?

My red line was that the delay - which ended up being 17 months long - in ratifying the USPSTF's "D" recommendation against PSA-based prostate cancer screening would ultimately injure hundreds of thousands of patients who accepted screening without being aware of the Task Force's determination that it was more likely to cause them harm than good. My primary professional identity was and remains that of a family physician, and inherent in this identity is an obligation to provide patients with the best understanding of the science to help them make health decisions. Being told that I had to set this obligation aside because it might damage the electoral prospects of a Presidential administration and his political party was, in my view, unconscionable.

On the other hand, I admire my colleagues at AHRQ who chose to stay and sustain the USPSTF from the inside. A few still work there; others, unfortunately, were given pink slips by Elon Musk's Office of Government Efficiency when his group of twenty-something contractors couldn't figure out what the agency did that was important enough to warrant employing a few hundred scientists. No doubt the Task Force would have been much worse off if every member of its support staff had walked out with me on my last day and switched to careers in academic medicine. Leaving an impossible situation can be courageous, but staying on is, too. I salute Dr. Monarez and her departed senior leaders at CDC for their principled public resistance, but I also support the many staff who have remained despite RFK Jr.'s horrific interference with the agency's mission to protect the public's health.