The True Meaning of Health Care

If you’d been reading last week’s obituaries, you might have stumbled upon the utterly fascinating tribute to Dr. H. Jack Geiger, the trailblazing physician whose humanitarian efforts led two of the groups he helped start to win Nobel Peace Prizes.

At the heart of Geiger’s work wasn’t cutting-edge technology or precision medicine. It was the recognition that physicians cannot turn away from the societal conditions that make people ill: poverty, hunger, unemployment, racism, inadequate education—factors that today are called social determinants of health.

Today, Dr. Geiger’s legacy can be seen in the tireless efforts of countless clinicians whose work strives to address the impact of poverty on Philadelphia, where nearly 25 percent of our population lives below the poverty line.

Among them: Dr. George Dalembert.

As a practicing pediatrician with a deep devotion to his patients, Dalembert forges strong bonds with the hundreds of babies, toddlers, kids, and teens he sees each year at CHOP’s Cobbs Creek practice in West Philadelphia.

“Our team has been able to meet people where they are,” Dalembert says. “So many families report that nobody’s ever sat down and talked to them about their financial situation before.”

And as a well-respected researcher in the field of social determinants of health (SDOH), Dalembert, like Geiger and so many others before him, also believes strongly that there are effective, data-backed ways to improve the lives of his patients and their families beyond administering throat cultures and ear exams, checkups and sick visits.

Through an innovative program he introduced, families of young patients at CHOP’s Nicholas and Athena Karabots Pediatric Care Center at 48th and Market streets and one other nearby West Philly clinic are offered the opportunity to have their taxes prepared, for free, on-site, and provided with financial counseling there as well.

Over the past two years, the program has been able to prepare hundreds of tax returns and return nearly $700,000 to the Philly community through tax refunds, the earned income tax credit (EITC), and the Child Tax Credit, two credits that have proven to be particularly useful to low-income individuals. At the CHOP clinics where the program is offered, 74 percent of families rely on Medicaid.

The program has enabled one family to buy their first home; another to pay off medical bills; countless others to pay off debt and improve their credit scores.

“That’s what led me to do this specific work and what keeps me motivated, these interactions with individuals who are able to take advantage of it—hearing their stories and seeing the impact that we’re having on their lives,” Dalembert says.

Lessons from StreetCred

Dalembert’s work is based on the success of StreetCred, a program out of Boston Medical Center founded by pediatricians Lucy Marcil and Michael Hole, that offers free tax preparation services to families receiving pediatric care at BMC, from the comfort of the waiting room. Through tax prep that has connected patients to the EITC and Child Tax Credits, StreetCred has returned more than $5.3 million to more than 2,700 low-income families since 2016.

Dalembert knew Marcil, as she’d been a resident at Penn before moving to Boston; he admired StreetCred’s impact, and was eager to figure out the most impactful approach to bringing something like it to Philly.

He launched the program with support from a CHOP Cares Grant and now receives funding from CHOP’s Healthier Together Initiative, which looks at innovative approaches to alleviating poverty and addressing social determinants of health in West Philadelphia, and the Possibilities Project, CHOP’s primary care innovation initiative. But he knew he’d need additional partners to have a meaningful impact.

He found his match in Campaign for Working Families, the Philly nonprofit that helps people with tax prep and asset-building; Campaign, as it’s informally called, now provides licensed, volunteer tax preparers to the clinic; he also forged a partnership with Clarifi, the Philly-based organization that helps people improve their credit, reduce debt, avoid foreclosure, and otherwise improve their financial well-being. Clarifi has provided the program with financial counselors.

Behavioral economics suggests that it’s a lot easier to get people to take advantage of an opportunity when it’s quite literally right there, on-site. “Once you’re plugged in, once you’ve started, you’re more likely to finish,” Dalembert says. And he’d made sure to survey patients before implementing any programming about what days and times they’d be most likely to have the flexibility to take advantage of these kinds of services (Thursday evenings and Saturdays).

Many other examples of this holistic approach to, this Geiger-ian lens on, medicine abound in Philly, as with Reach Out And Read’s (ROAR) focus on early literacy in the pediatric clinic setting; in-office voter registration drives; Penn ER physician Eugenia C. South’s work on the effect of urban blight on health; Fresh Rx, a program run through the St. Christopher Hospital Foundation, to provide discounted fresh produce boxes for patients.

“I see my babies relatively often, but I see my teenagers once a year, for 30 minutes. And that is not a lot of time to be able to make a huge impact on people’s lives. Not to say that I don’t have great connections with people, but it really leaves out so many of the other factors that are determining their life trajectories,” Dalembert says. “I really wanted to find something that addressed a social determinant and wasn’t just a guess, wasn’t just a hope, but something that had evidence behind it.”

As he sees it, his job isn’t to save or rescue his patients—as common as that tendency is among the helpers who are invariably drawn to medicine—but to educate and empower them about getting money they’re already entitled to, and making that money go further.

Igniting change

Marcil, of StreetCred, has all the metrics to back up the need for these kinds of programs; in addition to her other roles, she’s also the Associate Director for Economic Mobility at the Center for the Urban Child & Healthy Family, and part of the the Medical Tax Collaborative (MTC), a coalition of health systems and financial services agencies in 14 states and D.C. sharing best practices and technical support related to integrating wealth-building services into medical settings.

One in five eligible families nationally do not claim the EITC, yet those who do are often incentivized to work more, which can lift families out of poverty, and drive additional positive outcomes in education, health, and job opportunities. In Philly last year, over 188,000 people took advantage of the EITC, collectively earning around $500 million. Another 50,000 who qualified did not, leaving about $130 million with the federal government that could have been spent here. While the average cash back is $2,500, the credit ranges from about $500 to $6,550.

Still, Marcil finds anecdotes are often more compelling evidence than numbers.

“One of the first families we served was a grandmother who was raising her two-year-old grandchild on her own. She ended up getting back about $3,300, and she was just over the moon, especially because the year before she’d paid several hundreds of dollars to have her taxes prepared,” Marcil says. “She said to us Oh this is so great, now I’m going to buy these luxuries—I’m going to buy a winter coat and high chair for my child, and I’m going to buy fresh fruits and vegetables. If that doesn’t clarify the day-to-day financial toll and stress that most of our families are facing, I’m not sure what does. In the US, there are [these] basic needs that unfortunately a lot of people do see as luxuries.”

“One participant said, Oh this is so great, now I’m going to buy these luxuries—I’m going to buy a winter coat and high chair for my child. If that doesn’t clarify the day-to-day financial toll and stress that most of our families are facing, I’m not sure what does,” says Marcil.

Challenges as opportunities

The CHOP program hasn’t been without its challenges—no surprise, given how sensitive the issues of money and the IRS can be.

“There’s a lot of fear around the federal income tax system, and a lot of myths as well,” Dalembert says. But Clarifi’s counselors can help families take steps like setting up payment plans, so that the money they owe no longer counts against them if they’re, say, applying for a loan. “Our team has been able to meet people where they are,” Dalembert says. “So many families report that nobody’s ever sat down and talked to them about their financial situation before.”

Covid-19 has presented another obstacle, one that Dalembert has embraced as an opportunity for innovation; having had to pivot to working with clients over the phone, instead of in-person, he’s seen one possible way to scale services to additional CHOP clinics.

Up next, Dalembert is exploring introducing college savings programs, like Keystone Scholars, through which the Commonwealth seeds $100 in a 529 savings fund for every baby born in Pennsylvania. When they turn 18, that money is worth $500 that can be used towards college or other post-secondary training. The larger effect is to catalyze savings from families, so that number can help to cover the real costs of education.

“When I mention to my parents of newborns, Hey, you may not be thinking about it right now, but 18 years from now, you are going to have a big bill come to you and an amazing thing about math is how compounding can work for you,” he says. “Even if you invest a small amount every month, you can kind of quickly get up to having $10,000 set aside for those higher education needs.”

But as with everything else Dalembert does, he needs to study it first. “At each step, we’re validating what we call the ‘acceptability’ of incorporating something new into the pediatric practice. We never want to make assumptions; just because people should be excited about doing something doesn’t mean that they will be,” he says. He’s exploring how open newborn parents, in particular, may be. And he has ideas for future initiatives down the road.

Growth potential

Marcil, of StreetCred, sees real potential for Dalembert’s work to continue to grow.

“George has been a really dedicated, transformative leader,” she says. “Bringing partners from outside the medical world into a hospital system really takes skill and talent to maintain,” she says. “I really think George and his team are on their way to figuring out how to make this a replicable model that could return millions, if not hundreds of millions, of dollars to families in Philadelphia and infuse really needed cash for families.”

Already, Dalembert says, he’s had inquiries from other healthcare entities in Philly, like St. Christopher’s Hospital for Children, about introducing the program there. “Especially this year, when people are hurting in the setting of Covid-19 and layoffs and businesses being shut down, we have an opportunity to rally together and make sure that we are getting everybody the money that they are rightfully due this coming tax season,” Dalembert says.

In Geiger’s obituary last week, one of his peers said of him: “Jack redefined what it meant to be a physician…he felt it was our right and our responsibility as doctors to ‘treat’ hunger, poverty and disparities in health care as directly and openly as we treat pneumonia or appendicitis.”

And through his work at CHOP and, potentially, throughout the city, Dalembert is doing just that.

The Citizen is one of 20 news organizations producing Broke in Philly, a collaborative reporting project on solutions to poverty and the city’s push towards economic justice. Follow the project on Twitter @BrokeInPhilly.