​Beyond the Checklist: Financial Wellness in a Pediatric Medical Home

Molly A. Markowitz, MD

January 24, 2020

As a new pediatric resident working in a busy, urban, primary care clinic, some days feel like absolute chaos. I can’t remember when to check lead levels. I forgot which vaccines are needed at the 2-month well child check. And the nurse is asking how long before I can see the patient in room 4 as they have been waiting for over an hour. Complete chaos. But it is in moments like these when I forget my endless list of to-dos, that I am able to truly connect with families.

Recently on one such day, I noticed a grandmother did not meet my morning greeting with much luster. I looked up from my computer. “How are you doing?” I asked.

Her eyes dropped to the floor and an exhale blew through her lips. “I don’t know what we are going to do. I don’t know how I can pay the bills this month,” she said. This grandmother is the new caregiver of two young children at the age of 67. Her own daughter struggles from addiction, mental health issues and years of trauma.

I pushed my chair back away from the computer, which housed the list of well-child questions I had been prepared to ask. In that moment, I realized that asking about milk consumption, brushing teeth, and screen time was not what this family needed most. They were in crisis and we needed to talk not about medicine, but financial wellness. And more specifically, taxes.

Taxes might sound like a strange topic for a pediatrician to discuss with families, but that is exactly what I have been doing for the past year. StreetCred New Haven is a free tax preparation service that operates in the primary care clinic at Yale New Haven Children’s Hospital. It was launched two years ago by Leslie Sude, MD, a local community pediatrician.

How financial struggles can tax children’s health

Pediatricians routinely care for children with high rates of obesity, asthma, anxiety, depression, and behavior and learning disorders. Yet, Dr. Sude observed, it is a constant struggle to connect families with interventions and solutions. Fresh fruits and vegetables are expensive, safe places to play are limited, and parents’ jobs have schedules that do not allow for bedtime reading. Parents also suffer from high rates of depression and anxiety themselves, interfering with their ability to buffer their children from experiencing social and emotional stresses.

In the clinic, we have a list of referral services, including food banks, mental health care centers, weight management programs, and other social services. But it never feels like enough.

A few years ago, Dr. Sude spotted an AAP News article about an antipoverty initiative called StreetCred founded by two residents during their pediatric residency at Boston Medical Center. The article described how they provided free tax preparation services for families in the waiting area of their primary care clinic. Research later showed that the project saved these families hundreds of dollars. Inspired by this work, Dr. Sude decided to replicate the program in our Yale pediatric resident clinic.

Pediatric residents have no specific training in financial wellness. However, given the longitudinal relationships we forge with families and the trusted role we play in their lives, pediatricians and medical homes are in the perfect position to provide families with evidence-based guidance for financial interventions.

“It’s hard for families to think about watching less TV, reading bedtime stories, and buying more fruits and vegetables if the lights are about to be turned off, they don’t have a safe place to sleep, and can’t afford to get to a grocery store.”

There are two powerful financial tools all pediatricians need to be educated about: the Earned Income Tax Credit (EITC) and the Volunteer Income Tax Assistance (VITA) Program. The EITC is a tax credit available to working, low income families. According to federal data, roughly 25% of eligible people fail to claim billions of dollars in EITC each year. The VITA program is a federal free tax preparation service which enables individuals to maximize their refunds by avoiding expensive commercial tax preparation fees. However, 59% of EITC recipients use a paid preparer.

A medical-financial partnership was created when StreetCred New Haven, a VITA site, was embedded within our primary care clinic. This collaboration works because a pediatric medical home is a trusted and consistent presence in family’s lives. The lack of EITC and VITA utilization creates a critical opportunity for pediatricians to advocate for financial wellness.

During last year’s tax season, I spent many hours sitting in the clinic waiting area talking with families as they were having their taxes prepared. I administered a survey trying to better understand tax filing practices and perceptions of the clinic as a place for help with financial struggles.

Many happy returns

I listened to stories of hardship--bills unpaid, opportunities missed, and needs unmet. But then I heard accounts of how money saved through StreetCred will help families lead healthier, happier lives. I am always moved when I hear someone say, I am here today because a family member or friend told me StreetCred was a good place to have my taxes done. I then follow up and ask, “How did they learn about StreetCred?” They answer, “their pediatrician.”

We look forward to helping families again during this year’s tax-filing season, which begins January 27.

As pediatricians, the checklist of health and safety advice we share with parents and caregivers during wellness visits remains essential, of course. But we should also remember that it’s hard for families to think about watching less TV, reading bedtime stories, and buying more fruits and vegetables if the lights are about to be turned off, they don’t have a safe place to sleep, and can’t afford to get to a grocery store. For these vulnerable families, it helps to pause and provide resources and interventions that promote the financial wellness that’s the foundation for general family wellness.

*The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.

About the Author

Molly Markowitz, MD

Molly Markowitz, MD, a general pediatrics resident at Yale New Haven Children’s Hospital, is the National Resident CATCH Liaison for the American Academy of Pediatrics Section on Pediatric Trainees.

Editor’s note: Leslie Sude, MD, an Assistant Clinical Professor at Yale School of Medicine, also contributed to this post.