Episode 206: The Flint Episode | with Dr. Mona Hanna-Attisha and Dr. Luke Schaefer

Jeff Madrick:
Thanks so much for joining us for this episode of the Invisible Americans podcast. And we have good news from Flint, Michigan, the poorest city in Michigan, and one of the poorest in the country. A program called RX Kids is underway for every child born in the city. Financial support for the first year of their lives.

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Carol Jenkins:
Beginning at 20 weeks of pregnancy, every expectant person in Flint is eligible for a $1,500 payment, no questions asked, then $500 a month for the first year. We talk with the co-directors of RX Kids, Dr. Mona Hanna-Attisha, a pediatrician, and Dr. Luke Schaefer, a renowned researcher.  

Jeff Madrick:
As a reminder, 10 years ago, Flint, Michigan, a mostly black city, was known as the Poisoned City. In 2014, to save money while a new water pipe was being constructed, the city decided to take its water from the Flint River, which had been a toxic chemical dump for years. Children were poisoned by the lead in the pipes and had disastrous results. The doctor who confirmed the lead poisoning and was instrumental in leading to a $600 million settlement and replacement of the pipes is with us today.

Carol Jenkins:
Dr. Mona Hanna-Attisha, co-director of RX Kids, is founder and director of the Michigan State University Hurley Children's Hospital Pediatric Public Health Initiative and author of What the Eyes Don't See: A story of crisis, resistance, and hope in an American city.

Jeff Madrick:
Dr. Luke Schaefer, Ph.D. and co-director of RX Kids, is professor of social justice and social policy and a professor of public policy at the Gerald R. Ford School of Public Policy at the University of Michigan. He directs the Poverty Solutions Program there. He is the co-author of the books The Injustice of Place, Uncovering the Legacy of Poverty in America, and $2.00 A Day: Living on Almost Nothing in America

Carol Jenkins:
I said to you when we started this that I expected you to be a much older Dr. Mona because of what you have accomplished. And we'll talk about what you did in Flint with the water crisis after we talk about RX Kids. And of course, Luke Schaefer is one of our favorite people in the world. He's done our podcast before, has written an amazing book, as both of you have. And Jeff and Luke have worked together and know each other from previous work on child poverty. So having said all of that, we are very excited about RX Kids, the fact that you already launched. And when we first heard about this, Luke was telling us, there's this fabulous project that's coming down the pike and now you actually have mothers engaged in it. If you could tell us, Dr. Mona, what you've done now.

Dr. Mona Hanna-Attisha:
I'm so excited to talk about RX Kids. I'm so excited to be here with you, Carol and Jeff. Thank you for having us on and allowing us to share the story of RX Kids. So, ARCS Kids is this never, ever been done before effort to eliminate infant poverty. As a pediatrician, I, for a long time, have wished for this, like, ability to prescribe away poverty. I practice in Flint, Michigan, which is one of the poorest cities in our nation. 

And it breaks my heart that I can do a lot for kids. I can give them immunizations to prevent vaccine-preventable diseases. I talk about healthy eating and signing up for different programs and injury prevention and wear my helmet and back to sleep, all these things that I do for families and children to not just make sure they're healthy today, but really to make sure that they have the brightest future possible. 

But my hands have been tied because I have not been able to take away what makes them really sick and impacts their future, and that's being born into and growing up in poverty. So, RX Kids, it's a prescription for health, it's a prescription for hope, and it's a prescription for opportunity. We are prescribing cash to every pregnant mom and every infant in the city of Flint, and it launched in January 2024.

Jeff Madrick:
Well, congratulations. It's quite an extraordinary program. We're very impressed, and we've looked at a lot of programs. I do want to emphasize, which you already talked about, giving cash to kids, to poor kids, which seemed to be, when Luke and I first met, seemed to be prohibitive for a social policy. Now it isn't, so people are much more welcome in general, aren't they, for these cash social policies, all cash, unconditional social policies, quite an extraordinary evolution. What do you have to say about cash in Flint? Is there evidence it's working well?

H. Luke Schaefer:
Well, Jeff, you're absolutely right. There's been a sea change and we're all grateful for the pioneering work that you did and really making a lot of that possible. Some of the first papers that drew out a child allowance in Michigan, you really made possible, so thank you. And this builds on the incredible evidence of the expanded child tax credit, just to see child poverty plummet and things that we thought were impossible become possible and a real sea change in our understanding. And, you know, seeing food hardship fall to the lowest level ever and credit scores improve among families, and then for it not to be extended was an immense disappointment to us all. 

And I was sort of despondent. So thankfully got Mona's call about, you know, interest among Flint families and doing something like this. Uh, at first we looked at doing a child allowance for every kiddo in Flint and that got really, really expensive, really fast. And then we zeroed in and, you know, I've learned from hanging out with pediatricians that baby brain double in size in that first year, that the prenatal period is an incredibly important time for shaping life trajectories, too. 

So, this builds on the incredible success of the expanded child tax credit by doing a citywide program, not a lottery where a certain number get picked, but every family in the city gets it. It builds, I think, on our knowledge about the importance of universal programs. They don't stigmatize families. They don't create animosity among families who are just above the threshold and don't get it. 

And it builds on our knowledge on unconditionality that actually families are, from the expanded child tax credit, we can see what incredibly great stewards they are of the resources that they receive. And another really exciting part about it is that we were able to draw down TANF dollars to do this. So, this isn't just a philanthropic effort. It's got some sustainability about it because we've been able to use those TANF dollars.

Carol Jenkins:
And, Mona, about 1,200 children are born in Flint, Michigan, per year. That's the number you're operating on. And this project now has grown to, what, $55 million that you have so far?

Dr. Mona Hanna-Attisha:
That's our goal. Our goal is to raise $55 million to do this for five years of moms and babies. We've raised 43 million, so if you have any listeners out there that want to help us close our gap of 12 million, feel free to contact us. We will say yes and thank you, and it's a tax-deductible donation. So we've raised 43 million, and like Luke said, it's this beautiful public-private partnership. It is truly a village of folks from all kinds of sectors that have championed this effort and that are coming alongside families to launch RX Kids. 

Yeah, we estimate about 1,000 to 1,200 births per year, which is one of the reasons that we started this program in Flint. It's a small, big city. It's a manageable population. There's also great need. Once again, we're the poorest city in our state, one of the poorest in the nation, but we also have this built academic community-partnered infrastructure. This work has been informed and driven and partnered with amazing parents and moms and dads and even convened a group of pregnant parents who advised us and tested our intake form. 

And then lastly, another reason I would say that we are doing this in Flint and that we are doing this together, you know, Luke and I and our teams really have this track record of starting something and helping it turn into national policy. So, you know, our intent was never to end this in Flint, but our intent was really to translate this from one community to something that we do for all families.

Jeff Madrick:
Well, it's great work. What was the gunshot that allowed you both to realize this was possible? I mean, you must have been working for quite some time to say, oh, we're just trying to raise $55 million. But something must have made it seem truly possible.

Dr. Mona Hanna-Attisha:
It was a tofu Reuben sandwich. Luke and I had lunch together and that sealed the deal. And then we had a pinky promise that we were going to do this.

H. Luke Schaefer:
It was actually about a year ago after that fateful Tofu Rubin that we went to see the C.S. Mott Foundation and told them the idea and really just, they got right on board and invited us to come speak to their, their board of directors. A meeting I was actually late for and then yeah, when we realized we could potentially pull down TANF dollars. That was another, like, really big piece of the puzzle. 

So, Temporary Assistance for Needy Families, it's the block grant that came out of the 96 Welfare Law that we thought was a welfare-to-work program, but states figured out over the years that it's actually just an incredibly flexible funding stream where they could provide cash to families or if they wanted to do things like spend on college scholarships or on the foster care system, they could fit it in under one of the goals of the legislation. This includes reducing out-of-marriage births for one, reducing welfare dependency, and they really didn't have to do any other justification. 

So, dollars have just flown away from cash aid for families with kids to all sorts of things where the states are really just balancing their budgets on the dollar. So, this took advantage of a provision for non-recurrent short-term benefits that allows you to provide four months of aid during an acute economic crisis to families without triggering work requirements or time limits. or any of the reporting states have to do, well, not any, but most of the reporting. And we define childbirth as the acute economic crisis because that is when poverty spikes in the life course. People are the poorest right around the birth of a child because earnings go down and expenses go up.

Carol Jenkins:
You mentioned you had parental input in the form that would be used. What questions do you ask on that? As I understand it, it's guaranteed for every pregnant person in Flint.

Dr. Mona Hanna-Attisha:
We are working with an incredible partner called Give Directly. They are the cash administrator, and they are the ones that get people cash literally across the world. So, they are the ones that built this intake form with our input and with the inputs of moms and dads. And it is just a 10-minute intake form asking kind of those basic fundamental questions like, where do you live? Upload, like, residency verification. Are you pregnant? Upload that verification. How do you want to get your money? A direct deposit, like a, you know, pre-paid debit card. So, it's very efficient. 

And they do a really great job at safeguarding our moms, as well as fraud detection and enrolling folks. So, it's one thing that's just kind of beautiful about having a universal program is there's not those hoops that you have to jump through. And it really shares this different message to folks, one that isn't kind of riddled with shame and stigma, but one that is about dignity and love. And that's the messages that we're trying to convey, that we know how hard it is to raise a family, and that we're here walking alongside you. And you haven't done anything wrong to be part of this program. This is something that everybody deserves, and you are deserving and loved. 

And the unconditionality of the program also conveys these messages of trust. It's not paternalistic. We're not telling you what to do with your money. You know what you need for your family. I can't tell you what you need. And so that in and of itself conveys trust and agency and empowerment and freedom and choice. So there's kind of these really important values, starting from the intake form, that are built into this program that are hoping to shift the narrative of what it's like to grow up in poverty.

Carol Jenkins:
And you all felt that starting during pregnancy was important. We know many of the programs that start once the baby arrives, but you think that that incubation period is essential to the success of the program and the children.

H. Luke Schaefer:
Yeah, the way that we set up the program is that pregnant people receive $1,500 after 20 weeks of gestation. And it's meant to help expectant moms who are, you know, seeing their earnings decline, if they're able to work less, all the expenses coming up. And the evidence is just really, really clear that taking care of a mom and pregnancy is incredibly important for shaping the life course. And The program starts with that $1,500 and then after birth, it's $500 a month until a baby turns one. And so, it really comes alongside families. They know what to expect. There's no phasing it out with earnings. It can be the stable source.

Dr. Mona Hanna-Attisha:
These amazing messages of love and dignity. So it is really important to start in pregnancy. It's as preventative as possible.

Carol Jenkins:
Now, I noticed that in the information it says if you have proof of guardianship. What is that about? I mean, I, of course, translated to say, oh, if I'm a grandmother and I'm going to take care of this baby, maybe I qualify. How does that work?

Dr. Mona Hanna-Attisha:
Yeah, you're right. So, you know, the money in pregnancy goes to the mom, obviously, but once the baby is born, the money really follows the baby. So, if there's a change in guardianship or foster care or whatever, it stays with the baby.

Carol Jenkins:
Excellent. Grandmothers get their turn.

H. Luke Schaefer:
Exactly. And there's more and more families that have these multi-generational families and grandparents raising kiddos. And so it's important. You know, we thought the principle of the money follows the baby was important.

Carol Jenkins:
That's perfect. Perfect. And the research that you're doing, how does that turn out? Are there results that you expect to find?

Dr. Mona Hanna-Attisha:
I can share a little bit about numbers that we already have, even though we're only in month three of the program. So, we're almost at 500 moms who've enrolled, which is amazing, because if you look at estimated birth rates, we're almost at 100% saturation of our population. That's unheard of for anything I've ever done in the past in terms of a public health program or a medical program or a social program. Sometimes it's really hard to get people to sign up for things. But when its cash, people sign up. That's something that Luke taught me. So we're almost at 100% uptake, which is amazing. We've prescribed over $700,000 in cash, has gone out the door, which is also phenomenal. 

And then we know a little bit about the families that are enrolled, and about 60% of the moms, the annual household income is less than $10,000. So I'm gonna say that again, the annual household income of the vast majority of our enrollees is less than $10,000. This program is life-changing for our moms and our families to have this extra give to be able to support the families. the research, we are academics, we are disheveled academics, like there's a lot of research.

H. Luke Schaefer:
Yeah, we're really leaning on administrative sources of data. Mona and her team have this incredible community-driven research infrastructure built in the city, which is really like nothing else I've ever seen. So, we're able to draw on data from the health system. So, 95 percent of babies in Flint are born at one hospital, Hurley Hospital, and that's the same for the surrounding areas. So, we'll be able to take a look at all sorts of things like prenatal appointment visits and then birth outcomes. We're really, really interested in new mom outcomes and seeing, you know, if the money and the support and the message can lead to better outcomes and reduce disparities across families. We're actually really interested in child welfare data, too. 

So, another thing I did not know before I started this project is that the spike for out-of-home foster care placements is in that first year of life, and it's almost all neglect, which is often driven by poverty and income. And so, there's a very nice set of papers that show providing more money can really reduce that. So, we really want to impact that. We have data from family homeless shelters. We're hoping to reduce the number of families going into homeless shelters as well in that age range. So, it's really exciting because we've got you know, a plan for five years that we can just look at everything and get a sense of what kind of things are impacting.

Carol Jenkins:
Well, that is fantastic. We will be looking and listening, waiting to hear what the results are. It sounds like this is just absolutely the perfect way to do this in a city that desperately needs it. Dr. Mona, I do want to get a quick update on the lead poisoning problem in Flint, Michigan, that your book was so instrumental in helping to clear up. You know, we just got a notice that the city is in contempt. It's defaulted in some way after all of this time. Just let us know what's going on for that.

Dr. Mona Hanna-Attisha:

We're approaching the 10-year anniversary of the water switch. So, in April of 2014 is when under this bizarre, usurped state of where democracy was taken away, we were under financial emergency management, the decision was made to change our water source. This was done against the will of the people, the water wasn't treated properly, it was corrosive, it ate up the lead that was in our plumbing and subsequently exposed an entire population for a year and a half to lead in the water. 

So, from that moment on, our work has been in recovery, really kind of putting into place interventions to mitigate the impact of this crisis and really leaning on this period of early childhood. So, we've done some great things in Flint from, you know, brand new high-quality childcare centers to early literacy programs, trauma-informed care, mental health services, nutrition prescriptions, you know, the list goes on and on. And then there's also been that hard work of replacing the lead pipes. 

And that's where that contempt came in. There was a deadline to get the pipes replaced. The city has not met that deadline. There are still some few lead pipes that need to be replaced. But I do want to touch on kind of the national impact of what has happened in Flint. There's been some really positive ripple effects. Because of the water crisis in Flint, we've really kind of raised the nation's consciousness on a lot of things, be it drinking water, be it lead, be it environmental injustice, be it the deprivation so many of our children and our communities grow up in. And that's really informed national policy. The Infrastructure Act was the largest federal investment in water infrastructure. We included money to replace lead pipes. 

The EPA has the strongest lead and copper rule that's been proposed right now, mandating removal of lead pipes in the next decade. Lots of millions of dollars has gone into prevention efforts to make sure that we don't continue to react to crises but prevent them. And that's really kind of how RX Kids was born. You know, we are a city that many see as kind of the failure of government, the failure of what happens when we don't protect children. 

And we have come out of that, and we are sharing something that is really emblematic of how we are supposed to protect children, how we're supposed to invest in children, how government and society can stand alongside families to promote their health and development. So, I hope that folks don't come away with, you know, thinking about Flint as the water crisis, but really come away with thinking about Flint as this place where ideas and the possible things have happened to help our kids everywhere.

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Jeff Madrick:
And what's the next step? Obviously, you want this to go as nationwide as possible, probably globalized as possible. But what do we do? Obviously, you've been working with a relatively small population. Doing programs like ours helps build that, but what do Luke and you think are the most important steps you can take?

Dr. Mona Hanna-Attisha:
Based on the success of what we've already been able to accomplish, Governor Whitmer in Michigan has included $24 million in her next budget to expand this to other Michigan cities. That is fantastic, but we still need a philanthropic lift to make that happen. And then, you know, Luke and I, we have aspirations to make this global, you know, starting national. We would love to eliminate infant poverty nationally. And we would love to take this really kind of simple but genius idea all over the world.

Jeff Madrick:
What do your parents say when you talk about eliminating child poverty nationally?

H. Luke Schaefer:
Our parents are very proud and often ask me for help getting into our Internet. So that's the combination. But, you know, Jeff, it is like it's not an impossible vision to say that as a species we could eliminate infant poverty worldwide. Like, the numbers are not that big. And starting from, you know, the wisdom of pediatricians that say, and like, if we're really going to have transformational change in the world, you've got to start with prevention and investing in this critical period is the most important thing. So like, I think the most exciting thing about this project is like, it is all possible and the path to a very different world can start here.

Carol Jenkins:
We want to thank you so much for the work that you're doing, and we cannot wait to see the implications for our children in the future.

Dr. Mona Hanna-Attisha:
Thank you. Thank you so much for having us.

Carol Jenkins:
Thanks so much for joining us on the Invisible Americans podcast, available wherever you get your podcasts. But we urge you to visit our website for transcripts, show notes, research, and additional information about our guests and their work. That's www.theinvisibleamericans.com. Please follow us on social media and our new YouTube channel. And our blog posts are up on Medium as well as our website. That's www.theinvisibleamericans.com. Jeff and I will see you next time.

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