Speaker
Sumit Agarwal, MD, MPH, PhD
Assistant Professor
Division of General Medicine
University of Michigan
Keywords
Income Support; Cash Benefits; Low-Income Population
Key Points
- Low-income patients face several barriers to care and achieving better health. Co-pays prevent people from filling prescriptions; transportation barriers prevent patients from attending appointments; emergency departments take the place of primary care; and people cope with anxiety, depression, and/or substance use amid economic vulnerability.
- The research team sought to understand the effect of income support on health care utilization and health. They conducted a randomized controlled study of a cash benefit program led and implemented by the government of Chelsea, Massachusetts.
- Several features of the intervention made it uniquely suited to understanding the effect of income: it was recurring; it was a large amount relative to the baseline income in the community, which was around $1,500 per month; it was unconditional; there were no restrictions on how the money could be spent; and it was randomized.
- The research team assembled electronic health record (EHR) data from three major health systems in the Boston area. Participants were linked to their EHR records. Together, this data likely accounts for 77% of all acute care and 78% of all outpatient visits among Chelsea residents.
- Their primary outcome was the number of emergency department (ED) visits. Their secondary outcomes included ED visits by type; outpatient use; clinical measures; and COVID vaccination.
- The research team found a 27% reduction in emergency department visits, including hospitalizations, and a 21% increase in subspeciality care. There was no change in clinical measures nor in COVID vaccination rates.
- These findings raised two questions: 1) Were people utilizing the emergency room less because they were increasingly able to access and utilize outpatient care? 2) Given the decrease in emergency department use and hospitalizations, are there potential cost savings here?
- Dr. Agarwal suggested that substitution was likely not driving the decrease in emergency department utilization, noting that there was no change in the rate of primary care or urgent care visits, nor in prescriptions; the decrease in emergency department visits and increase in subspecialty care appeared in two distinct groups of people.
- The study team estimated that the decrease in acute care utilization resulted in savings of $450/person for the healthcare system. When discussing the cost of running a cash benefit program, Dr. Agarwal noted, it is important to acknowledge potential offsets as well.
Discussion Themes
The collaboration with the city of Chelsea simplified funding; the road to IRB approval; and obtaining community engagement and buy-in.
Cash transfer programs in the U.S. tend to fall in one of two categories: Programs that target certain low-income populations, i.e. families with children, and, increasingly, programs that target patients with substantial barriers to healthcare, i.e. pediatric cancer patients. Both will yield insights into how we can target a cash transfer intervention more broadly.
The effects were sustained in the months after the nine-month intervention period, albeit at slightly lower levels. However, it’s unlikely that this effect will be maintained in the long term; a one-time, brief cash infusion probably cannot overcome the cumulative disadvantages driving health disparities.
About 70% of the funds were spent at places where food was the primary product, namely grocery stores and markets. Roughly 20% were spent on retail; 4% on utilities; 1% on transportation; and 0.4% on alcohol and smoking. This represents a counterpoint to the concern often expressed about cash transfer programs: that the funds will be spent on tobacco and alcohol.