What if, the next time you went to the doctor, instead of a prescription for blood thinners you got one for cash? What if you walked out the door with $1,000 in your pocket instead of paying a copay?
This is the idea behind unconditional cash transfer programs, a new movement in foreign aid that also is being applied to public health. A small number of nonprofits (most notably GiveDirectly) are giving money to the poorest families in the poorest parts of the African continent — up to $1,000 over two years, no strings attached. In America, the equivalent amount would be about $80,000 donated every year per person to poor people in America.
It's a big risk, obviously, and could be hugely naive. Giving away money, no strings attached, opens funders up to all kinds of liabilities. People could waste their money on cellphones and lotto tickets — or worse, on booze, cigarettes and handguns. But so far, results abroad show one unexpected but welcome side effect: better health.
Research shows the most frequently purchased item is a metal roof for the family's home, to protect against the elements. Next, these families spend the money on healthier food. So far, there's no evidence of an increase in spending on so-called "goods of temptation," such as cigarettes and gambling.
So is it time to bring this idea to the U.S. and other developed nations?
Public health professionals are excited about the prospect because it helps address a few things that we have found nearly impossible to fix. The first is what's known as the social gradient of health, which essentially means that the less money you have and the less educated you are, the shorter and more painful your life probably will be. Most health innovations make this gradient worse by developing expensive and complicated treatments that require money to access and education to understand.
It seems painfully obvious that giving poorer people access to the most basic goods necessary to improve their health, like food and shelter, makes their health better. Instead of improving outcomes for the rich, cash transfers help prevent the worst outcomes for the poor, essentially raising the floor for health outcomes rather than the ceiling.
And don't think this is just a far-off foreign aid solution — many of the most prevalent and stubborn diseases in America are diseases of poverty. For example, the poorest states in America also have the highest rates of childhood obesity, poverty is linked to higher rates of asthma among schoolchildren, and poor people are more likely to suffer from depression.
We have tried more than one conditional cash transfer program in the United States, the most recognizable of which is Social Security. But the hoops poor people have to jump through to get the money they need from the Social Security Administration makes the program nearly futile; many have said they feel like negotiating their benefits is a full-time job in and of itself.
In 2007, Opportunity NYC piloted a conditional cash transfer program for New York City's poorest residents, and made a small but encouraging impact. Unfortunately the money involved, a maximum of $3,000 per year, was not enough to make a big change in these families' lives. If you're a family of four in New York City, the difference between making $33,000 and $36,000 a year won't pay the rent or get your kids into college.
The problem is, if we wanted to have the same degree of impact, we'd have to give people in the U.S. a lot more money than the people in Africa. That may sound unappealing, but we already spend a lot on our poorest citizens' health — it just happens after those people are already sick. That includes $190 billion a year spent on obesity alone. Why can't we repurpose just a fraction of that money toward addressing the poverty that in part causes these health problems?
Sure, the money would be hard to come by, but the ultimate obstacle preventing unconditional cash transfers in the United States is trust. There are many more tempting ways to blow your cash in Mississippi than in Kenya. It would take a real leap of faith for bureaucrats and politicians to hand over money to poor people in the U.S.
But maybe it's time to start prescribing some dough alongside medicine.
Benjamin Spoer is a PhD student at NYU's Global Institute of Public Health obsessed with urbanism, obesity, and community health.