Avigail: Hi, I'm Avigail Oren.
Lizzy: And I'm Lizzy Ghedi-Ehrlich.
Avigail: And we're your hosts for Scholars Strategy Network’s No Jargon. Every other week, we will discuss an American policy problem with one of the nation's top researchers, without jargon.
Lizzy: And of course, we don't know what day it is when our listeners are listening to this episode, but we are recording right now. It's about mid-June and folks are still talking about the budget bill in Congress and what the many voluminous propositions it has are going to mean for American taxpayers. And in the case of today's episode, mothers and babies, too, I'm to understand.
Avigail: It turns out that tax policy is actually a social determinant of health. Meaning that the taxes we pay or don't pay and the programs that we do or don't benefit from are really important to the ways that we care for our bodies, our minds, and our families.
Lizzy: Well, it certainly makes sense when you say it like that. But I don't think I typically think of those things as connected, and maybe I should. I mean, immediately the Child Tax Credit (CTC) comes to mind, the Earned Income Tax Credit (EITC). These are all programs that you may or may not directly benefit from. But even if you do, I know that tax policy famously is a space where sometimes it can be hard to tell what you're actually getting and what the consequences of that benefit are. And so I'm interested to learn more about that today.
Avigail: That's exactly right. So for this episode, I spoke to Dr. Jean Junior, who's an assistant professor of pediatrics at Northwestern University. Dr. Junior's work connects something that many of us don't usually link, which is tax policy and infant mortality, and she's joining us today from Sudan, where she's currently working with Doctors Without Borders.
Here's our conversation.
Avigail: Dr. Junior, thanks so much for coming on No Jargon.
Jean: Thank you so much for having me.
Avigail: So we're recording this on June 9th, and once again, Congress is locked in this high-stakes budget debate, and there's a lot of talk of extending Trump's 2017 tax cuts, making changes to Medicaid and the Affordable Care Act, cutting food stamps, and the future of the expanded Child Tax Credit is still up in the air.
And so we wanted to talk to you to help us make sense of what's at stake. So most people probably don't connect tax policy with healthcare and especially not something as serious as infant death, which is what you study. And your research really makes that connection clear. But before you walk us through the way that our tax system can shape people's health, I would love to hear about how, as an MD, you came to be interested in taxation. I don't think that's like a particularly common research interest for MDs. So tell us a little bit about how you came to your research agenda.
Jean: Thank you. Yeah. So first of all, you are right. It is not common at all. But I really came to medicine from the perspective of wanting to reduce human suffering. I went into pediatrics because I wanted to try my best to help ensure that all children have the chance to thrive. And when I came at medicine from that direction, I really started thinking about all of the factors that influence health. And social determinants of health or social influencers of health such as poverty, actually have an enormous impact on the health and wellbeing of children and people in general. And I kept on seeing this over and over and over again, in the United States, doing healthcare work abroad. And I kept on thinking, how could you just address poverty? Because if we could do that, we could maybe make so much of a difference in health outcomes. And I kept on coming back to these programs and policies that had a lot of evidence of impact.
So, for instance, programs such as cash transfers in low- and middle-income countries have really shown major impacts on wellbeing and multiple outcomes. That's where you just give cash directly to very low-income people in the United States. Programs like Medicaid, like food stamps, like the EITC—all have really solid evidence that they make an enormous impact on the health and wellbeing of children.
And it just occurred to me, it's so hard to design a new program or policy and ensure that it would actually have an impact on people's lives. So why not just fully fund or increase funding for these programs and policies that we know work. And then I had to ask myself, well, what's the best way to get the most funding possible? And really to fund major policies and programs at a large population scale you need to think beyond philanthropic funds. And think about other sources. And the main other source that's used to fund major population-wide policies and programs is our taxes, basically.
And so that's how I got interested in it because essentially when I kept working back to how I could think about how to maximize health outcomes, it always came back to these programs that just needed more funding that we already know have a major impact.
Avigail: So, I was wondering if you could walk us through the specifics of how taxes fund these programs you just mentioned or fund these policies you just mentioned?
Jean: So there are several links. So I think that a major concept is this idea that taxes and budgets and the public resources that we have as a society are very much interlinked, and sometimes those links are not apparent to people. When we pay taxes, that essentially goes into a pool of money that becomes the budget.
And that budget is like a pie that's divided up to fund different priorities, such as, providing money for a new school or providing funding for Medicaid, health insurance for people with low incomes or what have you. When you have the budget to fund those programs—so let's say Medicaid, food stamps, things like that—then out at the end of that comes the results of those programs. So more people can be enrolled in Medicaid. More people can have access to good schools. More people can have access to green space. Think of publicly-funded parks. And that all has effects on our lives that end up influencing our health, because we have the resources to make decisions that can improve our health and that can allow us to lead safe, healthy lives.
So those are kind of the links. It goes from taxes to budgets to programs and what we see, feel, experience as someone who is receiving services and benefits from the government.
Avigail: So, I'm going to stick with this analogy of the pie that you invoked.
Jean: I love that analogy.
Avigail: So, in your work, you talk about both tax revenue and tax progressivity. And both of these are methods of baking a really big pie. So, can you explain what those terms are? What do they mean, and why do they matter when we're talking about health?
Jean: Yes, so tax revenue is basically just how much money does the government have to spend on all of those programs and policies that impact people's lives. Tax progressivity basically is a measure of how taxes are kind of distributed in the population. So progressive taxes require wealthier or higher-income individuals to pay higher tax rates than less wealthy individuals.
In contrast, regressive taxes do the opposite. So they require lower-income individuals, less wealthy individuals to pay higher tax rates than the wealthy. And both of these have an impact. You can kind of think of the revenue as sort of the funding pot to provide programs, and then the progressivity is how that funding pot affects inequities or inequalities in society. So progressive taxes would tend to, for instance, lower inequality because they're resulting in wealthier people paying more in taxes in terms of proportion of their income. And regressive taxes do the opposite. Both of these can have effects on health.
Avigail: So, basically, a regressive tax is like asking the people who most need to eat the pie to do the most to make and bake it. Versus asking the people with the least need, for that pie to contribute.
And so I would love to now make the connection to infant mortality. So you did a study a few years ago that looked at more than two decades of data on tax policy and infant mortality across all 50 states. That was then published in JAMA Network Open. Can you tell us a little bit about what you found in that study?
Jean: Yeah, so this was a study that involved 148,336 infant deaths. So it looked at a very large sample. And, as you mentioned, it did extend throughout many years, so it looked at data ranging from 1996 to 2019. It found two major results. Number one, that increased tax revenue was associated with decreased infant mortality, and number two, that increased tax progressivity was also associated with decreased infant mortality.
Avigail: And one of the most striking findings was your estimate that hundreds of infant deaths could be prevented each year if states adopted these more progressive tax structures. What would that look like in practice? Are we talking about income, tax changes, tax credits, or something else?
Jean: Yeah, so there are a whole variety of mechanisms that states could use, and frankly, that the federal government could use, that could basically increase tax revenues and increase tax progressivity. And there are many examples. I can just give a few.
So, for instance, the Earned Income Tax Credit is a refundable tax credit for low-income workers, which basically means that when low-income workers go to pay their taxes at the end of the year, they get a credit back that is refundable, which means that they can actually get money back from the government where the government pays them rather than them paying taxes depending on how their income falls or what have you. That is a program that specifically lowers the tax burden of low-income workers and thus contributes to tax progressivity. So if you increased or expanded the Earned Income Tax Credit, you would be making the tax system more progressive.
Another piece that goes into tax revenue and tax progressivity is just what income tax rates are set at and for which segments of the population. There's an organization called the Institute for Taxation and Economic Policy, and they have a report called “Who Pays” that comes out every few years, and they list a whole range of different mechanisms that states can put in place to make their tax systems more progressive and more regressive.
So if you have higher-income tax rates and upper-income individuals, that is also another way to make the tax system more progressive. Other mechanisms like estate and inheritance tax, and lowering reliance on sales taxes, are other mechanisms that can make the tax system more progressive.
And then just increasing tax rates, for instance, income tax rates, corporate tax rates, et cetera, can expand or increase the tax revenue that governments are bringing in. So there is a whole menu of tools that governments could use to increase tax revenue and increase tax progressivity.
Avigail: So let's talk about the effect of these tax policies on mothers and infants. And let's try to personalize it a little bit. So let's think about either a specific patient or just we can go with a hypothetical patient and talk about how the taxes they pay or the benefits they receive might influence their maternal, preventive care or the care of their infant, that might contribute to their infant's health or mortality.
Jean: Yeah, so unfortunately there are many cases that come to mind that I have personally cared for that illustrate these connections. A very painful story that we see come into the emergency department is the infant who is found dead at home, often overnight, and the parents find the child obviously distraught. They call emergency medical services. The emergency medical services start trying to do CPR or cardiopulmonary resuscitation, the chest compressions. They give the emergency medicines. We do all the things. They get them to the hospital and we continue all of these efforts.
But many times, as soon as you get that phone call from the ambulance that's coming in, based on multiple factors like how long the baby has been lifeless for, how long they have been trying to resuscitate the child or get the child back, you know that the prognosis or the possibility of them surviving and surviving with a normally functioning brain, sometimes that is extremely low. And that is really hard and really devastating because you know that you're going to try your best for these children. And at the end, you may still have to sit face to face with that mother and say that despite the best efforts their child did not make it, their child has died. And that is just, I get chills just even talking about it because it's such a horrible experience for everyone involved.
And the thing is, when you take a look back—so from a doctor's perspective, I know I only have so many limited tools I can use to get this child back. The child's state might exceed those tools even with the best of care, even with perfect care. But then when you look back, you think about, “how did that baby die overnight?” You can think, for instance, of this concept of sudden unexplained infant death. Sudden unexplained infant death is this phenomenon where, without explanation, a child, an infant, can pass away overnight and this accounts for many infant deaths.
Okay so you take that and you think, well, “what contributes to sudden unexplained infant death? What are some of the risk factors, for instance?” And one example of a risk factor is secondhand smoke and smoking that the child is exposed to.
Okay. So you take a step back from that. And chronic poverty is associated with toxic stress, with elevated stress levels, and increased smoking rates during pregnancy. Okay. So then you get all the way back to poverty, our foe that basically makes it very hard sometimes for people to achieve excellent health.
And then once you get to the point of thinking about poverty as this underlying factor through this chain of events, then you can start saying, “well what are these programs and policies that can lower poverty?” And you come back around to the same sorts of programs and policies that I mentioned, Earned Income Tax Credit, Medicaid, Supplemental Nutrition Assistance for families.
And you say, well, “how can you fund those programs at scale?” And then you get back to taxes. And so that kind of takes step by step from what I see at the bedside with my finger on the pulse in the emergency department all the way to that tax policy that someone in Congress is thinking of without necessarily thinking of that baby who I'm seeing at bedside.
Avigail: I love how you laid that out. I'm a new mother myself and I also have chills thinking about losing my child, especially after nine pretty brutal months of pregnancy. But that baby has not yet paid taxes, right? It's really about, as you mentioned, going both upstream in the sense of the parent and of the state and federal tax policy.
I want to ask you though about this idea of a progressive tax system, because one argument we often hear is that a more progressive tax system can hurt the economy or drive away investment. Does your research at all respond to that concern?
Jean: That's a great question. So my research does not specifically look at that question. However, I do want to uplift research that has.
So one of the articles that I like to cite in my research is an article by Hope, et al. Basically a group of authors that did this huge study of all major tax cuts on the rich in 18 high-income countries all the way from 1965 to 2015, and they found that tax cuts for the rich did lead to higher income inequality as one might expect, but actually did not have any significant effect on economic growth or unemployment. And that's just one example of a study that is looking at this very point. So I think it's important to challenge that very commonly held idea.
I think one other piece, and this is more of a philosophical or values-based piece, an opinion of mine, is that we often think about gross domestic product, other economic indicators. But what if we centered indicators like health outcomes, like infant mortality, and put those in the same sort of level of priority as we put our economic indicators? And if you did that, then you might think of the well-being of a country differently if you thought of it more from a health perspective.
And at the same time, you could be making really sound tax and economic decisions along the way. So one of the other studies that I really like to cite or lines of research that I'd like to cite are studies that look at how much money you actually save in the long run by investing in these policies and programs that help children. Basically, using tax revenue to reduce child poverty is actually estimated to save money in the long term by increasing adult productivity and reducing crime and reducing healthcare costs. And this is one of the major reasons that I went into pediatrics is this aspect of prevention, that if you make wise investments early on in the person's life, you can save that person so much suffering in the long run. And also help save society as well from the consequences of that.
Avigail: So I would love to kind of do the same exercise you did a few minutes ago when you were talking about how poverty is related to infant mortality. What if we took that same story of a child coming into not the ER this time but maybe just a well visit or a pediatric clinic and walk back to an ideal tax system, but let's just say a more progressive tax system. What would that story look like?
Jean: So, I would love that story. So, let's take that story for instance. Okay. So let's say that you have a child and they are walking in for their well-child visit. They lived in a state that has happened to take on some of the recommendations, for instance, that have been made in the “Who Pays” report by the Institute on Taxation and Economic Policy, and they live in a state where there has been expansion of the Earned Income Tax Credit.
And let's say that this state also makes it easy to receive the Earned Income Tax Credit, which is sort of the opposite of what some of the current budget proposals in Congress are trying to do, and so they're able to go to their clinic. Their clinic has a partnership with a tax counselor who that family is able to speak with and they learn about the existence of their Earned Income Tax Credit and also of the Child Tax Credit, and they file their taxes and take advantage of that.
And then because of that, they have a couple of thousand extra dollars in their pocket. They're able to use that to buy food, to buy shoes. As a result, the mom is less stressed. The mom feels like she is better able to go out and take some productive steps to better the life of the entire family.
The mom quits smoking and gets a job, and there's the virtuous spiral from there. And then in the long run, the children go to school, they're not hungry. They're thus able to stay awake in class. They're thus able to do better in school. They're thus able to go to college and be better off themselves, and thus they have lower healthcare costs and are able to pay higher taxes in the future because they're in higher paying jobs. All of that goes back to tax decisions, tax policy decisions that were made and that really do have major effects on the life of this family.
And I think that in some ways when you're working patient by patient, one person at a time, you see the consequences of your actions so acutely. If you give an overdose to a patient, you will feel that and see that, and you will know how directly you harm that patient. And it hurts, it feels very bad if that happens. And Yet policy makers are making decisions that have major effects on people's lives and can mean life and death for many people. And I think that sometimes we don't see that connection.
It's almost as though I wish the mindset of a doctor where you’re really, really, really caring about each patient's life could be taken to the halls of Congress where they're looking at this and really thinking about the lives saved or lost that could be associated with the policy interventions that are chosen.
Avigail: That is a much nicer story.
Jean: Yes.
Avigail: You know, from your mouth to the policymaker's ears. So before we wrap up, I want to ask you about what you're doing this summer. You're currently in Sudan with Médecins San Frontier or Doctors Without Borders. What kind of work are you doing there? And what has that experience been like?
Jean: Yeah. So I am indeed working with Doctors Without Borders. Here in Sudan, I'm working as a pediatrician and it is a lot of patient care in a healthcare system that has extremely low tax revenue as well as the challenges of war that have had major effects on the healthcare system.
Currently, I am treating a lot of patients with measles. There's a measles outbreak, which many people in the United States have not seen. And I can guarantee you it is not something that I wish on anyone. Measles is a very horrible disease that causes a lot of suffering and can also very much cause death among children and no child deserves that.
And so it's a lot of caring for kids day by day and also training and empowering local staff to care for the children here to the best of their ability with the very, very, very limited resources available, and that makes for a very busy summer's worth of work.
Avigail: I bet. And, when you come back to the United States at the end of the summer, do you feel like this work is going to shift or influence your research in any way?
Jean: Definitely. So this clinical work that I do is the main driver of my research and the two are very much interlinked in my mind. And so I have an interest in how tax systems in the United States can fund these policies and programs that we know help children in the United States. And I also have a research interest in how tax policies and programs internationally can help fund health care systems in places as far away from the United States as the Sudan. And I see the two as very interlinked, and indeed there are policies out there, policies that govern tax havens, policies such as worldwide combined reporting and other mechanisms to prevent the shifting of taxes away from the government and health systems that need them.
And I see those as all interlinked and all kind of one in some ways, and that's what drives me to continue down this line of research, looking at the links between tax policy and health outcomes.
Avigail: I love that answer because, as you started talking, I was really thinking about the fact that national borders are an invention and disease crosses them without any regard.
Jean: Oh, yes!
Avigail: As you began speaking, I thought, “oh, we can't think about the health of any national population without thinking about it in a global context.” But then when you brought up tax havens and the fact that money also moves with probably shouldn't say no regard because there is some regulation, but you know, with also, with some impunity to national borders, we really do see the ways in which health and taxation are really related. We should be thinking about these issues much more globally than we are.
Jean: A hundred percent. If there's one take home, I would say to at least consider that taxes actually do or can possibly have major relevance for health, and if people can just make that connection, I think that we could both strengthen our tax policies and also strengthen our health outcomes for children in the United States and globally.
Avigail: Well, Dr. Junior, thank you so much for joining us and helping connect these dots between taxes, policy, and public health. Your research has really challenged us, as I sort of concluded, to think differently about what it means to build a healthier and more equitable society. So thank you so much.
Jean: Thank you very much.
Avigail: And thanks for listening. For more on Dr. Junior's work, check out our show notes at scholars.org/nojargon. No Jargon is the podcast of the Scholar Strategy Network, a nationwide organization that connects journalists, policymakers, and civic leaders with America's top researchers to improve policy and strengthen democracy.
No Jargon is the podcast of the Scholars Strategy Network, a nationwide organization that connects journalists, policymakers, and civic leaders with America’s top researchers to improve policy and strengthen democracy.
The producers of our show are Wendy Chow and Dominik Doemer.
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