Economic Well-Being And Health: The Role Of Income Support Programs In Promoting Health And Advancing Health Equity

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There is an extensive body of research examining the relationship between income and health, and this evidence, both correlational and causal, predominantly finds that higher income is associated with better health.¹^–⁵ Findings from large-scale observational studies indicate that people with lower incomes have shorter lifespans and greater morbidity relative to those with higher incomes and that these health risks are greatest among people living in poverty.¹^,² For example, in the United States, the difference in average life expectancy between the top 1 percent and bottom 1 percent of the income distribution is fifteen years for men and ten years for women.⁶ Moreover, the relationship between income and health is a gradient, with the prevalence of health risks decreasing with each increasing $15,000 increment of household income across the full distribution of Census Bureau income categories.⁷ (A figure illustrating this pattern in a nationally representative sample of US adults is in online appendix exhibit 1.)⁸ More recent work provides causal evidence that increasing household income through income supports can provide measurable benefits for health,⁵ including experimental studies of interventions among people with low incomes who are offered increased tax credits,⁹ conditional cash transfers,¹⁰ or the opportunity to live in higher-income neighborhoods.¹¹

Income inequality has important implications for understanding racial and ethnic inequalities in health. Systemic racism has perpetuated educational inequalities and lower-income employment among people who are Black or Hispanic, which may expose them to economic conditions that increase the risk for poor health.¹²^,¹³ Racial and ethnic inequalities are not, however, explained entirely by income: In one study with a nationally representative sample, researchers found an income gradient in life expectancy but also found a difference of more than three years between Black and White people at every income-level category.¹⁴

The federal government provides a financial social safety net for families with low incomes through programs that directly supplement income, including the Earned Income Tax Credit (EITC) and Temporary Assistance for Needy Families (TANF). These programs can improve health by providing a foundation for meeting families’ basic needs and supporting their participation in economic development. But some groups of families face critical challenges gaining access to income support programs,¹⁵ potentially deepening health disparities. For example, there are geographic disparities in access to EITCs (because states vary in whether they offer state EITCs), in EITC policies, and in EITC application processes. In addition, there are racial and ethnic disparities in TANF sanctioning (that is, applying financial penalties for rule violations), such that Black recipients may be more likely to face sanctions because of caseworkers’ discretion in imposing those sanctions.¹⁶ These inequities in access and participation can exacerbate health inequities among people who have low incomes, are members of racial and ethnic minority groups, are immigrants, or are living in rural locations. A critical challenge is identifying barriers to access and participation and developing strategies to increase equitable access to income supports.

In this article we summarize the importance of income for health, the safety-net programs that provide financial support to families with low incomes, and the challenges that families face in accessing these programs. This analysis sets the stage for several articles in this issue of Health Affairs that address equitable access to available income supports for families and caregivers. (Although federal programs such as the Supplemental Nutrition Assistance Program and various COVID-19 relief programs provide a safety net for economically vulnerable families, this article focuses on programs that provide direct financial support to families and have been in existence long enough to enable understanding of their relationship to health.) The articles present findings from the Robert Wood Johnson Foundation’s Equity-Focused Policy Research program, which has funded research to understand the sources of inequities in families’ access to income support resources, innovations to advance equity, and strategies for scaling up policies and approaches that effectively advance equity.¹⁷ The articles describe barriers in providing equitable access to these income support programs, as well as policies and practices that could increase equitable access. Providing financial security to these vulnerable families can ultimately translate to improved health and well-being within the population.

How Income Influences Health

Several decades of observational research have generally found that people with lower incomes are more likely to experience a greater burden of illness and premature death.¹^–³ In addition to having a lower life expectancy,⁶ adults at each higher category of household income have decreased prevalence of many diseases.⁷ Evidence of an income gradient is correlational, but it is a substantial effect that is well documented across a wide range of contexts and has a number of plausible mechanisms, and research on income supports provides evidence of a causal effect of income on health.⁵

Income is one domain reflecting a person’s socioeconomic status, along with wealth, educational attainment, and occupation. These constructs are highly related and difficult to disentangle from their associations with race and ethnicity, immigrant status, and residential locations.² Nevertheless, income may influence health in a distinct way by determining where people can live, what resources they can buy to maintain a healthy lifestyle, and how much stress they experience about their ability to financially support themselves and their families or about their relative social status within broader society.

Researchers have documented myriad ways by which income may influence health. People from households with high incomes are more likely to afford materials and services that help them stay healthy, live in communities with healthier environments and fewer exposures that are detrimental to health, experience lower levels of stress, and have better access to health care and preventive services.

Affording Materials And Services

The ability to afford materials and services to allow people to stay healthy can include having the financial resources to afford healthy food and beverages, a gym membership, or exercise equipment for physical activity; to access resources for quitting smoking; or to rent or purchase a home without environmental toxins.¹⁸

Living In Communities With Healthier Environments

The ability to live in a healthier environment entails avoiding exposures that are detrimental to health. For example, communities with higher-income residents have greater access to retail outlets that sell fresh produce and a lower density of fast food restaurants;¹⁹^,²⁰ more open space, sidewalks, and recreational facilities to support physical activity;²¹ high-quality schools and local services;²² and stronger social networks.²³ These communities also may have less pollution,²⁴ economic disinvestment,²⁵ and marketing of alcohol and tobacco products.²⁶

Experiencing Lower Levels Of Stress

People with higher incomes experience fewer stressors related to financial concerns, such as the fear of not being able to pay the rent or heating or electric bills, and they might live in communities with fewer threats in the environment, such as violence and crime.²² The cumulative effects of chronic stress can have detrimental physiological effects through the persistent activation of the body’s stress response, leading to disruptions in metabolism and the immune system.²⁷

Improved Access To Health Care And Prevention

People with higher incomes face fewer barriers to accessing health care because of their insurance status or factors related to affording the cost of care, such as deductibles and copayments. Data show that only about 6 percent of adults with a household income of $100,000 or more did not have a usual source of health care, but the rate was almost four times higher among adults with household incomes of $35,000 or less.⁷ Because they have greater access to care, people with higher incomes tend to receive preventive health services such as cancer screening and immunizations at higher rates.²⁸

Independent of its relationship to health, income inequality is also a concern because it has widened significantly during the past half-century and may have important implications for economic mobility and political stability.²⁹ Given the correlation between income and health, policies and programs that contribute to families’ financial security through tax credits, cash transfers, and other safety-net programs may positively influence their health and well-being, and there is a growing body of causal evidence to support this.⁵

Impacts Of Safety-Net Programs

Effects On Income

Despite eligibility requirements and application procedures that limit access, several income support programs can directly increase family income. Two such models are the EITC and TANF. (A summary table with eligible populations and benefits associated with the EITC and TANF is in appendix exhibit 2.)⁸ The EITC is a refundable tax credit from the federal government to workers with low incomes to incentivize work and reduce poverty, particularly among families with children. To qualify, employed people must meet income qualifications and file an income tax return. The credit equals a fixed percentage of income up to a maximum that varies based on the number of dependent children. TANF is a cash transfer program for underemployed or unemployed adults who are pregnant or have a dependent child. Federal TANF law requires that states engage TANF recipients in work-related activities. There is no federal individual work requirement per se, but states must meet a “work participation rate” at the population level, and states may establish their own policies regarding who must participate and what activities satisfy work requirements.³⁰ States can also implement different TANF rules, including time limits for receiving TANF benefits and financial sanctions for noncompliance with work requirements.³¹ TANF differs in several respects from its predecessor program, Aid to Families with Dependent Children—notably in that TANF is a time-limited benefit and that beneficiaries may receive wage income and still be eligible for assistance.

Influences On Health

There is considerable evidence that safety-net programs that increase income are associated with improved health outcomes.

There is considerable evidence that safety-net programs that increase income are associated with improved health outcomes. For example, EITC receipt has been associated with reduced maternal smoking,³²^,³³ improved self-reported maternal mental health,³⁴^,³⁵ and improvements in biological markers of stress.³⁴ For children, family EITC receipt has been associated with reduced incidence of low birthweight³⁶^–³⁸ and preterm birth,³⁷ as well as parent-reported health status.³⁹ In contrast to these positive findings, EITC receipt also has been associated with a higher risk for obesity among women⁴⁰ and children.⁴¹ Nevertheless, because the evidence generally suggests that the EITC supports health, inequitable access to it could compound health inequities.

There is less research focused on how TANF receipt affects health, but stricter TANF policies, such as time limits, have been associated with negative health outcomes. Because TANF requires states to meet population-level work participation rates (and because some states impose individual-level work requirements), it is difficult to separate the effects of additional income from employment.⁴² In six welfare-to-work demonstration sites, an in-depth study, published in 2001, of outcomes for children who were preschool age at the time of random assignment found that children’s outcomes related to psychosocial development, academic functioning, and health and safety were largely unchanged.⁴³ However, more recent research finds that more stringent TANF policies are associated with worse maternal mental health.⁴⁴ Similarly, loss of TANF benefits resulting from exceeding TANF time limits increases the probability of being uninsured and decreases the likelihood of having annual medical provider contact.⁴⁵ Finally, there is causal evidence that TANF receipt has led to a lower life expectancy relative to the less stringent Aid to Families with Dependent Children program that it replaced, suggesting that more generous income support programs improve health outcomes.⁴⁶

In sum, although the evidence (some of it experimental) broadly supports a link between income supports and a range of health benefits, not all studies support this link, and some show negative effects, such as the EITC being associated with an increase in body weight.⁴⁰^,⁴¹ Challenges to identifying links through research include limited receipt of benefits by participants and short follow-up times.

Inequitable Access To Income Supports

Despite the health benefits of income support programs, families with low incomes do not have equitable access to them.

Despite the health benefits of income support programs, families with low incomes do not have equitable access to them. Research shows that there are inequities in access to these programs among eligible families with young children, with geography, immigration status, family structure, and race and ethnicity all affecting access. Overall take-up rates for the federal EITC are relatively high, and the nature of it being a refund ensures that this credit is more readily accessible to those who file tax returns.⁴⁷ Still, some families with low incomes are unable to access the EITC. During the period 2011–18, take-up rates were around 80 percent among eligible families,⁴⁸ likely because some families who had low incomes did have earnings but did not file taxes or did not claim the credit when they did file.⁴⁹ People are more likely to claim the credit when using professional tax preparers, who are less common in rural areas.⁵⁰^–⁵² More generally, the Internal Revenue Service could remove lack of filing as major barrier by calculating taxes on its own (for which it already has all of the necessary data) and sending them to earners for their approval.⁵³ Other inequities in access by immigration status and family structure are the result of eligibility criteria. Moreover, the EITC is predicated on work, so access to the EITC is affected by the strength of the labor market. During the Great Recession, the EITC disproportionately benefited married couples with children over single mothers with children.⁵⁴ Similarly, Hilary Hoynes and Diane Schanzenbach highlighted that work-dependent tax credits such as the EITC are not able to protect families during economic downturns and periods of high unemployment.⁵⁵ Moreover, because Black families face higher unemployment rates,⁵⁶ in economic downturns they are more likely to lose access to the EITC and face a weakened safety net during those downturns.

Whereas the federal EITC program treats all low-income working families the same, states and localities that offer their own EITCs increase income. However, variation in state EITC policies and the generosity of benefits creates geographic disparities in access to income support. In all, twenty-eight states and Washington, D.C., offer state EITCs,⁵⁷ and major urban areas such as New York City have implemented their own credits using city funds.⁴⁸ State and local EITCs vary in the size of benefits, ranging from 3 percent to 50 percent of the federal credit.⁴⁸ In addition, only some states and localities provide EITC benefits to noncustodial parents, which results in geographic disparities based on family structure.⁵⁸

In contrast to the relatively high take-up of the federal EITC, few eligible families receive TANF benefits: Only 21 percent of families in poverty received TANF benefits in 2020.³⁰ In addition, benefit levels are not adequate to move families out of poverty, and they vary across the country, reflecting historical inequities embedded in the TANF funding structure.¹⁶^,⁵⁹^,⁶⁰ In 2021 the maximum benefit that a family of three could receive ranged from $204 per month in Arkansas (11 percent of the federal poverty level) to $1,098 per month in New Hampshire (60 percent of the poverty level), with a median of $498 per month (27 percent of the poverty level).³⁰

In addition to setting benefit levels, states have broad discretion to determine TANF rules, resulting in geographic and racial and ethnic disparities in access and uptake.³⁰^,⁶¹^,⁶² For example, some states impose strict work requirements and time limits, and some states have no exemptions from work requirements for pregnant women or heads of household with young children.⁶³ States in which a large share of the population is Black tend to have more restrictive TANF policies and less generous benefits.¹⁶ Although federal law bars states from using federal TANF funds to assist most legal immigrants until they have been in the United States for at least five years, some states use their own funding to serve recent legal immigrants.³¹

There are also racial and ethnic disparities in TANF sanctioning and in access to supplemental TANF services. Black people are more likely to face sanctions for not complying with work requirements, and this disparity in sanctioning might be driven in part by caseworkers’ discretion in imposing sanctions.¹⁶^,⁶⁴ In addition to facing higher sanction rates than White TANF recipients,⁶⁵ Hispanic and Black TANF recipients can also face disparities in access to supplemental TANF services, including child care subsidies, transitional Medicaid, and transportation assistance.⁶⁶

Conclusion

In this article we demonstrate how low household income can negatively affect health and argue that this may be responsible for large-scale racial and ethnic inequities in health. We present research that suggests that existing income support programs such as the EITC and TANF can positively influence health by increasing household income. We also show, however, that there is inequitable access to these programs, which can exacerbate health disparities. Policy and program changes are necessary to ensure equitable access to supports among different groups of people who differ by race and ethnicity, geographic location, or immigration status. Ultimately, sweeping policy changes, such as universal access to health care and needed income support, could also have an important impact on health outcomes. In the articles that accompany this analysis, researchers highlight drivers of inequitable access to income supports and demonstrate how increasing equitable access could advance health equity in the United States.

ACKNOWLEDGMENTS

This research was supported by Grant No. 77456 from the Robert Wood Johnson Foundation as part of its Equity-Focused Policy Research Initiative: Building Evidence on Income Supports for Low-Income Families with Young Children. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/.

NOTES

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