OBJECTIVES:

The earned income tax credit (EITC), refundable monies for America’s working poor, is associated with improved child health. Yet, 20% of eligible families do not receive it. We provided free tax preparation services in clinics serving low-income families and assessed use, financial impact, and accuracy.

METHODS:

Free tax preparation services (“StreetCred”) were available at 4 clinics in Boston in 2016 and 2017. We surveyed a convenience sample of clients (n = 244) about experiences with StreetCred and previous tax services and of nonparticipants (n = 100; 69% response rate) and clinic staff (n = 41; 48% response rate) about acceptability and feasibility.

RESULTS:

A total of 753 clients received $1 619 650 in federal tax refunds. StreetCred was associated with significant improvement in tax filing rates. Of surveyed clients, 21% were new filers, 47% were new users of free tax preparation, 14% reported new receipt of the EITC, and 21% reported new knowledge of the EITC. StreetCred had high client acceptability; 96% would use StreetCred again. Families with children were significantly more likely to report StreetCred made them feel more connected to their doctor (P = .02). Clinic staff viewed the program favorably (97% approval).

CONCLUSIONS:

Free tax services in urban clinics are a promising, feasible financial intervention to increase tax filing and refunds, save fees, and link clients to the EITC. With future studies, we will assess scalability and measure impact on health. StreetCred offers an innovative approach to improving child health in primary care settings through a financial intervention.

What’s Known on This Subject:

Poverty is detrimental to child health. The earned income tax credit can be used to reduce poverty but is underused. Twenty percent of families who could receive it do not, and $2 billion annually is lost to for-profit tax preparers.

What This Study Adds:

Free tax services in clinics maximize tax filing and refunds, are feasible, and are acceptable to families and clinic staff. This intervention is scalable given the prevalence of catchment clinics, dedicated staff, and community-based Volunteer Income Tax Assistance organizations.

One in 5 children in the United States lives in poverty, increasing risk of delayed development, disease, poor educational outcomes, and decreased economic productivity for 16 million children.1,2 Reducing poverty is crucial to improving US child health, yet poverty rates have plateaued since the Great Recession.3 The earned income tax credit (EITC), an antipoverty, prowork, federal refundable credit is a powerful tool; in 2015, coupled with the child tax Credit, it reduced or eliminated poverty for 13.2 million children.4 Eligibility for EITC is dependent on age, filing status, social security number status, employment income, and the number of qualifying children.

However, 20% of eligible households do not claim this tax credit.5 In addition, individuals who receive EITC lose $1.75 billion to for-profit tax preparers yearly, despite eligibility for free tax preparation.6 EITC recipients pay 13% to 22% of their credit for these services. Although free tax sites exist in most communities via Volunteer Income Tax Assistance (VITA), they often have limited hours, capacity, and accessibility. Moreover, for-profit preparers target poor families; low-income neighborhoods have 75% more for-profit preparers than affluent ones.6 

The EITC is associated with health and economic benefits, including decreased maternal smoking and infant mortality, improved maternal mental health, increased food security, birth weight, term births, breastfeeding, employment rates of single mothers, child educational achievement, and long-term earnings when children become adults.7,20 The American Academy of Pediatrics has committed to “eliminating child poverty.”21 Because the EITC is a preexisting program used to reduce childhood poverty, maximizing its use is essential.

Consequently, an urgent need exists to connect families to accessible, acceptable free tax preparation. Pediatricians are uniquely-positioned, trusted professionals interacting regularly with low-income families; ˃90% of children ˂2 years old see a doctor yearly.22 In response, we developed StreetCred, which we use to offer free tax preparation integrated into the medical home. To our knowledge, this is a novel approach; some tax sites colocate with health clinics, but none are integrated. We aim to decrease financial stress and maximize tax refunds, particularly EITC, among low-income families.

We piloted StreetCred in New England’s largest safety net hospital and 3 community clinics to test our hypothesis, as follows: integrating free tax preparation into clinics serving children (1) ensures families file taxes and receive accurate tax preparation maximizing tax credits and refunds, (2) is feasible in medical clinics, and (3) is acceptable to families and clinic staff.

In 2016, we implemented StreetCred in Boston Medical Center’s (BMC) pediatric clinic. Services were available to all families with taxable income. In 2017, we expanded to South End Community Health Center, Martha Eliot Health Center, and a community clinic within the Boston Health Care for the Homeless Program.

We advertised via physician referrals, fliers in mailed appointment reminders, clinic advertisements, and calls to families with upcoming appointments. Although our target population was families with children, we also used StreetCred to serve low-income hospital or clinic employees and adults without children, including patients from other clinical areas in the hospital or clinic who encountered our advertising and individuals referred from other tax preparation sites within the Boston Tax Help Coalition because of wait times or convenience. We used privacy screens and Health Insurance Portability and Accountability Act–compliant procedures. We operated January to April 2016 and 2017 with concurrent client recruitment. To balance accessibility with feasibility, we offered services 15 to 25 hours weekly, including evenings and weekends.

Walk-in visits and appointments, in conjunction with a medical appointment or other convenient time, were available. During scheduling, families learned about required tax documents (eg, identification, wage and tax statements, etc). If scheduled with a medical appointment, families arrived 15 minutes early to complete intake, went to their appointment while taxes were prepared, and returned to finalize their return after the visit.

Within each site, predominately minority, low-income, and Medicaid-insured patients are served; many patients are non-English speaking. We advertised in English, Spanish, and Haitian Creole. Interpreter services were available. Some tax preparers were bilingual.

The Boston Tax Help Coalition, an umbrella organization used to coordinate Boston’s VITA program, was used to train volunteer tax preparers. A VITA-certified site coordinator supervised volunteers and managed logistics. The program cost $8000–$10 000 per site, largely in site coordinator salaries (based on VITA norms). Partner sites covered this cost and provided in-kind resources (space, computers, etc). Grants, corporate donations, and private philanthropy covered central programming costs (1 full-time staff salary, marketing materials).

We conducted surveys to assess the intervention’s feasibility, acceptability, and impact among (1) StreetCred clients, (2) nonparticipating clinic families, and (3) clinic staff (Supplemental Fig 1).

Among clients, we surveyed a convenience sample to assess experiences with StreetCred and previous tax preparation. We pretested this survey via a needs assessment in 2015. Participants completed this anonymous, written survey immediately after completing the tax return. Surveys were in English, Haitian Creole, Spanish, and Portuguese. In 2016, research volunteers asked clients to complete the survey and offered a raffle incentive; in 2017, to increase survey availability, tax preparers asked clients to complete the survey when time permitted without an incentive.

We conducted a phone survey in 2016 with nonparticipating BMC pediatric clinic families to assess perceptions of StreetCred. This 3-question survey was multiple choice and free response. Research volunteers called families with upcoming appointments and offered StreetCred’s service; if they declined, volunteers asked families to complete a survey. Volunteers used interpreter services for non–English-speaking families and offered clients a raffle entry after survey completion.

Additionally, we e-mailed anonymous English-language surveys, which contained 5 multiple choice and 3 free response questions, to all BMC pediatric clinic staff in 2016 to assess perceptions of and experiences with StreetCred. Deidentified data regarding total tax return and EITC amount were available for all clients via Internal Revenue Service–provided tax software (TaxWise in 2016; TaxSlayer in 2017). Because of the brevity of staff and nonparticipant surveys, we did not pretest them. Research volunteers completed institutional review board training and followed written guides on survey administration.

Impact

Primary measures were total money refunded and EITC returned. Additional measures, relative to client’s self-reported past, included percent change in clients filing taxes, receiving free tax preparation services, and knowledge and receipt of EITC.

Feasibility

Measures included the following: the percentage of tax returns completed in 1 visit, mean self-reported visit length, clinic staff’s perception of StreetCred’s impact on clinical workflow, nonparticipant families’ reasons for declining services, and program cost.

Acceptability

Measures included the following: the clients’ self-reported overall experience; percent of participants and nonparticipants interested in using StreetCred’s services next year; whether using StreetCred made clients feel more connected to their doctor; whether services were timely, private, and convenient; and whether tax preparers were knowledgeable and trustworthy. Clinic staff acceptability measures included staff perception of whether StreetCred was appropriate and relevant and whether StreetCred should continue.

We calculated descriptive statistics regarding overall client population and regarding impact, feasibility, and acceptability from the tax software and client databases and client, nonparticipant, and provider surveys, respectively. We stratified and analyzed client survey data by (1) children ≤18 years old, (2) site, and (3) year for BMC (the only site existing for 2 years). We examined group differences by using Fisher’s exact test, χ2 test, or analysis of variance; 2-sided P values < .05 were considered significant. Data were managed in Research Electronic Data Capture and descriptive analyses were completed by using Stata (Stata Corp, College Station, TX), Microsoft Excel, and Research Electronic Data Capture. Ten percent of surveys underwent double entry to ensure minimal entry errors. The Boston University Institutional Review Board deemed this study exempt.

StreetCred prepared taxes for 753 clients (186 in 2016; 567 in 2017) who were a combination of pediatric clinic families, patients from other clinical areas, hospital employees, and unaffiliated taxpayers; significant overlap existed among categories (Table 1). In total, we surveyed 254 clients, which were 34% of the total StreetCred clients; 10 surveys were excluded for missing all demographic data for a sample of 244 (42 in 2016; 202 in 2017). We called 144 nonparticipants that resulted in a sample of 100 (69% response rate). Forty-one clinic staff responded to the staff survey (48% response rate); 38 were aware of the program and could complete the survey. StreetCred client survey participants were predominantly minorities (45% black, 30% Hispanic), low-income (40% below the poverty line), single (76%), and English-speaking (73%) (Table 2). Families with children ≤18 years old were more likely to identify as multiracial, have a lower education level, and live below the federal poverty line than families without. Additionally, they were more likely to have heard of EITC and to report receiving EITC in the previous year (Table 2).

TABLE 1

Affiliation of StreetCred Client Population (n = 725)

Affiliationn (%)
Health care–affiliated taxpayers 463 (64) 
 Patient 140 (19) 
 Patient and parent of pediatric patient(s) 93 (13) 
 Patient and employee 90 (12) 
 Employee 73 (10) 
 Patient, employee, and parent of pediatric patient(s) 37 (5) 
 Parent of pediatric patient(s) 26 (4) 
 Employee and parent of pediatric patient(s) 4 (1) 
Nonaffiliated taxpayers 262 (36) 
Affiliationn (%)
Health care–affiliated taxpayers 463 (64) 
 Patient 140 (19) 
 Patient and parent of pediatric patient(s) 93 (13) 
 Patient and employee 90 (12) 
 Employee 73 (10) 
 Patient, employee, and parent of pediatric patient(s) 37 (5) 
 Parent of pediatric patient(s) 26 (4) 
 Employee and parent of pediatric patient(s) 4 (1) 
Nonaffiliated taxpayers 262 (36) 

Missing data on 28 of 753 total clients; all missing data from 2017 is due to inconsistency in tax software reports.

TABLE 2

Surveyed StreetCred Client Demographics and Previous Tax Filing Behavior

All ClientsClients With Children ≤18 yClients Without Children ≤18 y
n = 244n = 98an = 131a
Mean (SD) or n (%)Mean (SD) or n (%)Mean (SD) or n (%)Pb
Demographics (n 
Age in y (SD) (n = 235)c 37 (13) 36 (10) 38 (15) .25 
Race and/or ethnicity (n = 242)d — — — .02* 
 Black, non-Hispanic 110 (46%) 48 (50%) 55 (42%) — 
 Hispanic 72 (30%) 30 (31%) 40 (31%) — 
 White, non-Hispanic 32 (13%) 6 (6%) 24 (19%) — 
 Asian 15 (6%) 5 (5%) 8 (6%) — 
 Other 13 (5%) 8 (8%) 3 (2%) — 
Highest level of education completed (n = 243)e — — — <.01* 
 College degree or higher 96 (40%) 27 (27%) 65 (50%) — 
 Some college or technical school 71 (29%) 36 (37%) 32 (25%) — 
 High school graduate, GED, or Eq 56 (23%) 25 (26%) 24 (18%) — 
 Did not complete high school 20 (8%) 10 (10%) 9 (7%) — 
Marital status (n = 243)e — — — .13 
 Single (living without partner) 184 (76%) 71 (73%) 103 (79%) — 
 Married 29 (12%) 9 (9%) 17 (13%) — 
 Divorced 19 (8%) 11 (11%) 6 (5%) — 
 Widowed 2 (1%) 1 (1%) 1(1%) — 
 Living as a couple 9 (3%) 6 (6%) 3 (2%) — 
Primary language (n = 240)f — — — .39 
 English 175 (73%) 71 (75%) 95 (73%) — 
 Spanish 33 (14%) 11 (12%) 20 (15%) — 
 Haitian Creole 13 (5%) 8 (8%) 5 (4%) — 
 Other 19 (8%) 5 (5%) 10 (8%) — 
Have children ≤18 y old (n = 229) 98 (43%) — — — 
Living in poverty in 2017 (n = 161)g — — — <.01* 
 Below the federal poverty line 65 (40%) 37 (54%) 26 (29%) — 
 At or above the federal poverty line 96 (60%) 32 (46%) 64 (71%) — 
Previous tax preparation behavior and knowledge  
Filed taxes last y (n = 237)h 188 (79%) 74 (76%) 105 (82%) .40 
Paid to file taxes last y [amount range] (n = 188)i 57 (30%) [$30, $465] 26 (35%) [$40, $465] 28 (27%) [$30, $300] .22 
Ever used a free tax preparation service (n = 237)j 126 (53%) 48 (51%) 72 (56%) .37 
Experienced barriers to using free tax preparation services in the past 121 (50%) 45 (46%) 66 (50%) .54 
Specific barriersk  .35 
 Didn’t know it existed 88 (73%) 33 (73%) 48 (73%) 
 Couldn’t get there 3 (2%) 2 (5%) 1 (2%) 
 Couldn’t go when it was open 6 (5%) 4 (9%) 2 (3%) 
 I prefer to use a paid service, or I don’t need help with my taxes 8 (7%) 1 (2%) 5 (8%) 
 Other 22 (18%) 5 (11%) 11 (17%) 
Ever heard of EITC (n = 238)l 89 (37%) 47 (48%) 39 (31%) .03* 
Received EITC last y (n = 236)m — — — <.01* 
 Yes 55 (23%) 37 (38%) 17 (14%) — 
 No 119 (51%) 36 (37%) 75 (60%) — 
 Not sure 62 (26%) 24 (25%) 33 (26%) — 
All ClientsClients With Children ≤18 yClients Without Children ≤18 y
n = 244n = 98an = 131a
Mean (SD) or n (%)Mean (SD) or n (%)Mean (SD) or n (%)Pb
Demographics (n 
Age in y (SD) (n = 235)c 37 (13) 36 (10) 38 (15) .25 
Race and/or ethnicity (n = 242)d — — — .02* 
 Black, non-Hispanic 110 (46%) 48 (50%) 55 (42%) — 
 Hispanic 72 (30%) 30 (31%) 40 (31%) — 
 White, non-Hispanic 32 (13%) 6 (6%) 24 (19%) — 
 Asian 15 (6%) 5 (5%) 8 (6%) — 
 Other 13 (5%) 8 (8%) 3 (2%) — 
Highest level of education completed (n = 243)e — — — <.01* 
 College degree or higher 96 (40%) 27 (27%) 65 (50%) — 
 Some college or technical school 71 (29%) 36 (37%) 32 (25%) — 
 High school graduate, GED, or Eq 56 (23%) 25 (26%) 24 (18%) — 
 Did not complete high school 20 (8%) 10 (10%) 9 (7%) — 
Marital status (n = 243)e — — — .13 
 Single (living without partner) 184 (76%) 71 (73%) 103 (79%) — 
 Married 29 (12%) 9 (9%) 17 (13%) — 
 Divorced 19 (8%) 11 (11%) 6 (5%) — 
 Widowed 2 (1%) 1 (1%) 1(1%) — 
 Living as a couple 9 (3%) 6 (6%) 3 (2%) — 
Primary language (n = 240)f — — — .39 
 English 175 (73%) 71 (75%) 95 (73%) — 
 Spanish 33 (14%) 11 (12%) 20 (15%) — 
 Haitian Creole 13 (5%) 8 (8%) 5 (4%) — 
 Other 19 (8%) 5 (5%) 10 (8%) — 
Have children ≤18 y old (n = 229) 98 (43%) — — — 
Living in poverty in 2017 (n = 161)g — — — <.01* 
 Below the federal poverty line 65 (40%) 37 (54%) 26 (29%) — 
 At or above the federal poverty line 96 (60%) 32 (46%) 64 (71%) — 
Previous tax preparation behavior and knowledge  
Filed taxes last y (n = 237)h 188 (79%) 74 (76%) 105 (82%) .40 
Paid to file taxes last y [amount range] (n = 188)i 57 (30%) [$30, $465] 26 (35%) [$40, $465] 28 (27%) [$30, $300] .22 
Ever used a free tax preparation service (n = 237)j 126 (53%) 48 (51%) 72 (56%) .37 
Experienced barriers to using free tax preparation services in the past 121 (50%) 45 (46%) 66 (50%) .54 
Specific barriersk  .35 
 Didn’t know it existed 88 (73%) 33 (73%) 48 (73%) 
 Couldn’t get there 3 (2%) 2 (5%) 1 (2%) 
 Couldn’t go when it was open 6 (5%) 4 (9%) 2 (3%) 
 I prefer to use a paid service, or I don’t need help with my taxes 8 (7%) 1 (2%) 5 (8%) 
 Other 22 (18%) 5 (11%) 11 (17%) 
Ever heard of EITC (n = 238)l 89 (37%) 47 (48%) 39 (31%) .03* 
Received EITC last y (n = 236)m — — — <.01* 
 Yes 55 (23%) 37 (38%) 17 (14%) — 
 No 119 (51%) 36 (37%) 75 (60%) — 
 Not sure 62 (26%) 24 (25%) 33 (26%) — 

GED, general equivalency development; —, not applicable.

a

Could not stratify 15 surveys because of missing responses for number and/or age of children. Thus, numbers from clients with children and without children do not necessarily add up to the total number for all clients because of excluded surveys. Data from 2017 only consists of 80 surveys for clients with children and 111 surveys for clients without children.

b

P value compares results for clients with and without children ≤18 y old.

c

Missing response on 7 surveys for clients without children.

d

Missing response on 1 survey each for clients with and without children.

e

Missing response on 1 survey for a client without children.

f

Missing response on 3 surveys for clients with children and 1 survey for a client without children.

g

Not measured in 2016. Income was defined as money from a job, personal business, pensions, unemployment insurance, cash benefits from assistance programs, alimony, or child support. Federal poverty level in 2016: single person ($11 880), family of 2 ($16 020), family of 3 ($20 160), family of 4 ($24 300). Could not stratify 11 surveys because of missing responses for number and/or age of children. Thirty-two surveys were excluded (11 with children, 21 without children) because of missing or unsure income or missing family size.

h

Missing response on 1 survey for a client with children and 3 surveys for clients without children.

i

Excluded participants who did not file taxes last year.

j

Missing response on 3 surveys each for clients with and without children.

k

Respondents could select ≥1 barrier.

l

Missing response on 5 surveys for clients without children.

m

Missing response on 1 survey for a client with children and on 6 surveys for clients without children.

*

Denotes significant differences.

Pediatric-specific sites (BMC, St. Mary’s Center for Women and Children) were more likely to serve families with children than community health centers (South End Community Health Center, Martha Eliot Health Center) (47%, 56%, 29%, and 29%, respectively; P = .04). The only significant difference at BMC between 2016 and 2017 was clients reporting ever using free tax preparation (45% vs 62%; P = .04). This increase may be attributable to repeat StreetCred clients; in 2017, 36% of those who had ever used free tax preparation used StreetCred in 2016 (data not shown).

Overall, clients received $1 619 650 ($401 275 in 2016; $1 218 375 in 2017) in federal refunds with $438 883 ($96 209 in 2016; $342 674 in 2017) from EITC (Table 3). StreetCred was associated with an additional 21% filing taxes compared with self-reported, previous year filing status (100% vs 79% [P < .0001]; Table 3).

TABLE 3

Impact, Feasibility, and Acceptability Measures for StreetCred

All Clients or RespondentsClients With Children ≤18 yClients Without Children ≤18 y
n = 98an = 131a
Mean (SD) or n (%)n (%)n (%)Pb
Impact  
Clients (n = 732)c Total federal tax return: median [range]d $1172 [$1, $10 130] — — N/A 
 Received federal EITC 268 (37%) — — N/A 
 Total federal EITC (if received): median [range] $925 [$2, $6269] — — N/A 
Clients (n = 244 surveyed) New tax filing (compared with previous y) (n =237)e 49 (21%) 23 (24%) 23 (18%) .29 
 New to free tax preparation services (n = 237)f 111 (47%) 47 (49%) 56 (44%) .39 
 New knowledge of the EITC (n = 238)g 54 (23%) 28 (29%) 23 (18%) .07 
Feasibility  
Clients (n = 244 surveyed) StreetCred tax filings completed in a single visit (n = 188; 2017 only)h 156 (83%) 66 (89%) 85 (82%) .25 
 Length of StreetCred visit <1 h (n = 224)i 77 (34%) 31 (34%) 42 (34%) .96 
Clinic staff (n = 38) StreetCred impact on ability to do job and/or clinical work flow — — — N/A 
  Very positively or positively 7 (18%) — — — 
  Did not impact 31 (82%) — — — 
  Very negatively or negatively 0 (0%) — — — 
Nonparticipants (n = 100) Top reasons for declining StreetCred services (could endorse ≥1) — — — N/A 
  I have already filed my taxes for a fee 57 (57%) — — — 
  I plan to prepare my own taxes 13 (13%) — — — 
  I plan to pay to prepare my taxes 10 (10%) — — — 
  I do not need to file 9 (9%) — — — 
  I plan to have my taxes prepared for free elsewhere 8 (8%) — — — 
  I have already filed my taxes for free 5 (5%) — — — 
Acceptability  
Clients (n = 244 surveyed) Overall experience with tax services (n = 241)j — — — .35 
  Excellent 205 (85%) 86 (90%) 106 (81%) — 
  Very good 27 (11%) 7 (7%) 18 (14%) — 
  Good 9 (4%) 3 (3%) 6 (5%) — 
 Interest in using StreetCred next y (n = 240)k    .63 
  Yes 230 (96%) 92 (97%) 124 (95%) — 
  Not sure 8 (3%) 3 (3%) 4 (3%) — 
  No 2 (1%) 0 (0%) 2 (2%) — 
 Getting tax services done at my clinic or hospital makes me feel more connected to my doctor (n = 176; 2017 only)l    .02* 
  Definitely agree 103 (58%) 44 (59%) 52 (58%) — 
  Mostly agree 38 (22%) 22 (29%) 13 (14%) — 
  Mostly disagree 23 (13%) 7 (9%) 15 (17%) — 
  Definitely disagree 12 (7%) 2 (3%) 10 (11%) — 
 Satisfied with the amount of time it took to do my taxes here (n = 237)mm    .87 
  Definitely agree 202 (85%) 85 (88%) 105 (84%) — 
  Mostly agree 31 (13%) 11 (11%) 18 (14%) — 
  Mostly disagree 2 (1%) 1 (1%) 1 (1%) — 
  Definitely disagree 2 (1%) 0 (0%) 1 (1%) — 
 There was enough privacy where my taxes were prepared (n = 238)nn    .99 
  Definitely agree 187 (79%) 75 (79%) 100 (78%) — 
  Mostly agree 45 (19%) 18 (19%) 25 (20%) — 
  Mostly disagree 5 (2%) 2 (2%) 3 (2%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
 There was enough privacy where my taxes were prepared (n = 238)on    .91 
  Definitely agree 210 (89%) 87 (90%) 111 (88%) — 
  Mostly agree 24 (10%) 9 (9%) 14 (11%) — 
  Mostly disagree 2 (1%) 1 (1%) 1 (1%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
 My tax preparers were knowledgeable about taxes (n = 238)pp    .64 
  Definitely agree 216 (91%) 88 (93%) 115 (90%) — 
  Mostly agree 21 (9%) 7 (7%) 13 (10%) — 
  Mostly disagree 0 (0%) 0 (0%) 0 (0%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
 I trust the tax preparers here (n = 240)q    .66 
  Definitely agree 215 (90%) 86 (89%) 116 (91%) — 
  Mostly agree 24 (10%) 11 (11%) 12 (9%) — 
  Mostly disagree 0 (0%) 0 (0%) 0 (0%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
Nonparticipants (n = 100) Interest in using StreetCred next yr — — — N/A 
  Yes 64 (65%) — — — 
  Not sure 17 (17%) — — — 
  No 18 (18%) — — — 
Clinic staff (n = 38) StreetCred is appropriate and relevant service for clinic families 37 (97%) — — N/A 
 StreetCred services should be provided for clinic families next y 37 (97%) — — N/A 
All Clients or RespondentsClients With Children ≤18 yClients Without Children ≤18 y
n = 98an = 131a
Mean (SD) or n (%)n (%)n (%)Pb
Impact  
Clients (n = 732)c Total federal tax return: median [range]d $1172 [$1, $10 130] — — N/A 
 Received federal EITC 268 (37%) — — N/A 
 Total federal EITC (if received): median [range] $925 [$2, $6269] — — N/A 
Clients (n = 244 surveyed) New tax filing (compared with previous y) (n =237)e 49 (21%) 23 (24%) 23 (18%) .29 
 New to free tax preparation services (n = 237)f 111 (47%) 47 (49%) 56 (44%) .39 
 New knowledge of the EITC (n = 238)g 54 (23%) 28 (29%) 23 (18%) .07 
Feasibility  
Clients (n = 244 surveyed) StreetCred tax filings completed in a single visit (n = 188; 2017 only)h 156 (83%) 66 (89%) 85 (82%) .25 
 Length of StreetCred visit <1 h (n = 224)i 77 (34%) 31 (34%) 42 (34%) .96 
Clinic staff (n = 38) StreetCred impact on ability to do job and/or clinical work flow — — — N/A 
  Very positively or positively 7 (18%) — — — 
  Did not impact 31 (82%) — — — 
  Very negatively or negatively 0 (0%) — — — 
Nonparticipants (n = 100) Top reasons for declining StreetCred services (could endorse ≥1) — — — N/A 
  I have already filed my taxes for a fee 57 (57%) — — — 
  I plan to prepare my own taxes 13 (13%) — — — 
  I plan to pay to prepare my taxes 10 (10%) — — — 
  I do not need to file 9 (9%) — — — 
  I plan to have my taxes prepared for free elsewhere 8 (8%) — — — 
  I have already filed my taxes for free 5 (5%) — — — 
Acceptability  
Clients (n = 244 surveyed) Overall experience with tax services (n = 241)j — — — .35 
  Excellent 205 (85%) 86 (90%) 106 (81%) — 
  Very good 27 (11%) 7 (7%) 18 (14%) — 
  Good 9 (4%) 3 (3%) 6 (5%) — 
 Interest in using StreetCred next y (n = 240)k    .63 
  Yes 230 (96%) 92 (97%) 124 (95%) — 
  Not sure 8 (3%) 3 (3%) 4 (3%) — 
  No 2 (1%) 0 (0%) 2 (2%) — 
 Getting tax services done at my clinic or hospital makes me feel more connected to my doctor (n = 176; 2017 only)l    .02* 
  Definitely agree 103 (58%) 44 (59%) 52 (58%) — 
  Mostly agree 38 (22%) 22 (29%) 13 (14%) — 
  Mostly disagree 23 (13%) 7 (9%) 15 (17%) — 
  Definitely disagree 12 (7%) 2 (3%) 10 (11%) — 
 Satisfied with the amount of time it took to do my taxes here (n = 237)mm    .87 
  Definitely agree 202 (85%) 85 (88%) 105 (84%) — 
  Mostly agree 31 (13%) 11 (11%) 18 (14%) — 
  Mostly disagree 2 (1%) 1 (1%) 1 (1%) — 
  Definitely disagree 2 (1%) 0 (0%) 1 (1%) — 
 There was enough privacy where my taxes were prepared (n = 238)nn    .99 
  Definitely agree 187 (79%) 75 (79%) 100 (78%) — 
  Mostly agree 45 (19%) 18 (19%) 25 (20%) — 
  Mostly disagree 5 (2%) 2 (2%) 3 (2%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
 There was enough privacy where my taxes were prepared (n = 238)on    .91 
  Definitely agree 210 (89%) 87 (90%) 111 (88%) — 
  Mostly agree 24 (10%) 9 (9%) 14 (11%) — 
  Mostly disagree 2 (1%) 1 (1%) 1 (1%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
 My tax preparers were knowledgeable about taxes (n = 238)pp    .64 
  Definitely agree 216 (91%) 88 (93%) 115 (90%) — 
  Mostly agree 21 (9%) 7 (7%) 13 (10%) — 
  Mostly disagree 0 (0%) 0 (0%) 0 (0%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
 I trust the tax preparers here (n = 240)q    .66 
  Definitely agree 215 (90%) 86 (89%) 116 (91%) — 
  Mostly agree 24 (10%) 11 (11%) 12 (9%) — 
  Mostly disagree 0 (0%) 0 (0%) 0 (0%) — 
  Definitely disagree 1 (0%) 0 (0%) 0 (0%) — 
Nonparticipants (n = 100) Interest in using StreetCred next yr — — — N/A 
  Yes 64 (65%) — — — 
  Not sure 17 (17%) — — — 
  No 18 (18%) — — — 
Clinic staff (n = 38) StreetCred is appropriate and relevant service for clinic families 37 (97%) — — N/A 
 StreetCred services should be provided for clinic families next y 37 (97%) — — N/A 

—, not applicable.

a

Could not stratify 15 surveys because of missing responses for number and/or age of children. Thus, numbers from clients with children and without children will not necessarily add up to the total number for all clients because of excluded surveys. Data from 2017 only consists of 80 surveys for clients with children and 111 surveys for clients without children.

b

P value compares results for clients with and without children ≤18 y old.

c

Missing data on 20 clients because of inconsistency in tax software reports.

d

Excludes returns in which clients owed taxes.

e

One hundred percent of clients filed taxes compared with clients who reported filing in the previous year (Table 2). Missing response on 1 survey for a client with children and 3 surveys for clients without children.

f

One hundred percent of clients received free tax preparation serviced compared with clients who reported ever using free tax preparation services in the past (Table 2). Missing response on 3 surveys each for clients with and without children.

g

Twenty-one percent responded “Yes, I learned about it today” when asked if they had heard for the EITC. Missing response on 5 surveys for clients without children.

h

Missing response on 6 surveys for clients with children and 7 for clients without children.

i

Missing response on 7 surveys for clients with children and 9 surveys for clients without children.

j

Missing response on 2 surveys for clients with children and 1 survey for a client without children.

k

Missing response on 3 surveys for clients with children and 1 survey for a client without children.

l

Missing response on 5 surveys for clients with children and 21 surveys for clients without children.

m

Missing response on 1 survey for a client with children and 6 surveys for clients without children.

n

Missing response on 3 surveys each for clients with and without children.

o

Missing response on 1 survey for clients with children and 5 surveys for clients without children.

p

Missing response on 3 surveys each for clients with and without children.

q

Missing response on 1 survey for a client with children and 3 surveys for clients without children.

r

Missing 1 response.

*

Denotes significant differences.

StreetCred was associated with significantly increased knowledge and receipt of EITC. After using StreetCred, an additional 21% of clients knew about EITC compared with baseline (58% vs 37% [P < .0001] Table 3); 37% of clients received EITC compared with 23% of surveyed clients who reported “definitely” receiving it the previous year (P < .0001) Table 3. However, the rate of EITC receipt in the previous year likely exceeded 23%, because 26% were “not sure” of their EITC status. If we exclude those “not sure,” the change in EITC receipt is nonsignificant (P = .19).

Additionally, StreetCred was associated with significant increase in access to free tax preparation services, with an additional 47% of clients receiving free tax preparation compared with the previous year (100% vs 53% [P < .0001] Table 3). Of the 50% of clients who reported barriers to free tax preparation, 73% were unaware free tax services existed. Of the 79% of clients who filed taxes in the previous year, 24% across both years paid for tax services, with fees ranging from $30 to $465 (Table 2). Notably, 39% paid to file taxes in the previous year in 2016 compared with 23% in 2017 (P = .25) (data not shown).

No significant differences in impact existed between families with children ≤18 years old and families without (Table 3).

Only 17% of surveyed clients in 2017 required ˃1 visit to complete tax returns (Table 3). No differences existed in feasibility between families with children and families without. Most visits were unrelated to medical care; only 10% reported scheduling a tax visit in conjunction with a medical appointment.

Most surveyed nonparticipants were eligible for the service but declined because they already filed taxes (62%); only 9% reported not needing to file.

All clinic staff survey respondents reported StreetCred’s services either did not impact (76%) or positively impacted (24%) their work. One stated, “many of our patients’ families struggle to make ends meet… which can have a negative impact on our pediatric patients... Anything to help alleviate that stress is a valuable part of our clinic.”

Services were highly acceptable to both clients and clinic staff. Of surveyed clients, 96% would use StreetCred again, and 96% rated overall tax services as “excellent” or “very good” (Table 3). Most clients “definitely” (59%) or “mostly” (22%) agreed StreetCred made them feel more connected to their doctor; pediatric families were significantly more likely to agree with this statement than families without children (P = .02; Table 3). No other differences existed in acceptability between families with children and families without. Most “definitely” or “mostly” agreed services were convenient (99%) and efficient (98%), volunteer tax preparers were trustworthy (100%) and knowledgeable (100%), and privacy was adequate (98%). One client found the service appealing “because it’s free, and you guys know what you all are doing. I have very limited funds.” Additionally, 64% of nonparticipants would consider using StreetCred in the future. Among clinic staff, 97% of respondents believed StreetCred was an appropriate, relevant service and should be continued (Table 3). Another staff member stated, “more money in parents’ pockets improves children’s health and reduces stress at home.”

StreetCred is a promising financial intervention. Given poverty’s negative impact on child health, addressing financial stability of families should be a priority for pediatricians.21 Of the federal antipoverty programs, tax credits, including the EITC and child tax credit, impact child poverty rates most; the Supplemental Nutrition Assistance Program, housing subsidies, and Temporary Assistance for Needy Families, among others, are important but lift fewer children from poverty (supplemental poverty measure).23,26 Authors of some studies find the EITC’s antipoverty effect underestimated, because, in most analyses, the credit’s prowork effect is not accounted for.27 Additionally, cash transfer programs like the EITC and Canadian Healthy Baby Prenatal Benefit improve maternal and infant health.8,10,28,29 Given these findings, alongside the knowledge that for-profit tax preparers target EITC-eligible families and 20% of eligible taxpayers miss out entirely, pediatricians have a unique opportunity to improve health by integrating financial interventions into medical homes. In our first 2 years, we returned $1 619 650, including $438 883 in EITC, to families. We reached a vulnerable population: 40% of surveyed clients and 54% of families with children ≤18 years old, were in poverty, which is markedly higher than national averages (14.8% and 17.6%, respectively).3 Notably, families with children ≤18 years old were significantly more likely to report StreetCred made them feel more connected to their doctor than those without (P = .02); emphasized in this difference is the potential bidirectional benefits of integrating tax preparation into pediatric clinics.

Using StreetCred was associated with increased filing rates, receipt of EITC, and use of free tax preparation, all of which increase money for low-income families. Additionally, there is concern about the accuracy of services provided by for-profit preparers. The Government Accountability Office estimates 60% of private-preparer returns have errors, compared with 6% of VITA returns.6,30 

Many free tax services exist through VITA, but half of our clients had never used them. Only 3% of EITC returns are prepared via VITA sites.31 We must better serve EITC-eligible families. StreetCred’s high acceptability provides evidence for a desired alternative of having tax services integrated into medical homes. Doctors’ offices are one of the only spaces all families with young children frequent.22 Anecdotally, we find families comfortable sharing their financial struggles when we introduce ourselves as a pediatrician-endorsed service.

Clinical services that are focused on social determinants of health are increasingly popular.32,33 Given limited time and space, we must prioritize services that families and staff find impactful. With our findings, we suggest StreetCred may be one such service. Not only did clients and clinic staff almost universally report acceptability, nonparticipants were interested in using it in the future. This highly acceptable service, measured both by self-report and by rate of return at BMC in 2017, served as both a community and pediatric-specific resource.

Whether referrals to free tax preparation services in the community have similar impact is unknown. The data on screening and referral to outside services are mixed regarding whether patients connect.33,35 One specific reason may be that families prefer for-profit services like H&R Block for their professional, branded experience connoting trust and reliability.36 Community VITA sites are often underfunded with limited hours, long lines, and unfamiliar locations. With StreetCred, we offer a nonprofit alternative fusing the benefits of typical VITA sites, like free services and knowledgeable staff, with the credibility and accessibility of for-profit businesses.

Notably, most surveyed clients in our pilot did not have young children. Only 40% of families surveyed had children ≤18 years old. Possible explanations include barriers parents face because of child care or single mothers more often living in families without an employed adult.37 Additionally, given locations within clinics in which multigenerational patients are served, our services act as a community resource for low-income individuals of all family compositions. Not surprisingly, community health center sites were less likely to serve families with children than pediatric-specific sites, emphasizing the importance of prioritizing pediatric settings. Finally, despite direct advertising to families, recent feedback reveals that many need a more in-depth discussion to understand the service.

We are implementing changes to better reach families with young children. To increase provider referral rates, we are piloting several interventions, such as advertising to families with wall posters in exam rooms, employing a provider incentive program, and using provider focus groups. To address competition with adults without children, we are reserving appointment slots for parents or caregivers of children.

Convenience samples limit our findings’ generalizability because they may not represent all clients, nonparticipants, or staff. The independence of these anonymous surveys is unknown, which may confound results; the same respondent may have responded to 2 years of client surveys or to a client and staff survey. Further, we were unable to calculate a response rate for client surveys because of variability in administration given program constraints; bias may be present if tax preparers differentially offered surveys to clients on the basis of unknown characteristics. Potential response bias may also limit generalizability; participants who chose to respond may not be representative of the whole population. Data on previous-year EITC status may be subject to misclassification because recall bias may be present. The reported increased feeling of connection to the doctor after tax preparation is limited because we do not know if participants were referring to their or their children’s doctor. Finally, we did not assess whether StreetCred has health impact or cost-effectiveness.

Given these encouraging findings, we will undertake a rigorous evaluation of the monies returned to families through StreetCred compared with the monies returned via usual tax preparation. Additionally, we will evaluate whether integrating StreetCred into medical homes impacts health care use. Finally, we will test replicability by scaling to a variety of settings, including states outside Massachusetts, rural settings, and homeless shelters.

Integrating tax preparation into pediatric clinics to improve child health is a novel intervention. Similar to the initial expansions of Reach Out and Read and Medical Legal Partnership, StreetCred’s expansion will depend on the early adapters of dedicated clinicians in safety net settings. VITA’s national presence may contribute to scalability. As clinicians dedicated to improving children’s health, we must financially empower our patients’ families; providing tax preparation services may be 1 approach.

     
  • BMC

    Boston Medical Center

  •  
  • EITC

    earned income tax credit

  •  
  • VITA

    Volunteer Income Tax Assistance

Dr Marcil conceptualized and designed the study and drafted the initial manuscript; Dr Hole assisted with the study design and reviewed and revised the manuscript; Drs Marcil and Hole jointly developed and implemented the StreetCred program; Ms Wenren reviewed and revised the data collection instruments, coordinated and supervised data collection, conducted the initial analyses, and reviewed the manuscript; Dr Schuler assisted with and provided critical input on framing study objectives, analytic design, and data analysis and reviewed and revised the manuscript; Drs Zuckerman and Vinci provided critical input on StreetCred development, implementation, and study design and reviewed and revised manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by Boston Medical Center (BMC) Department of Pediatrics, Boston Children’s Hospital Frederick Lovejoy grant, Boston Children’s Hospital House Officer Award, Food for Thought, the Janey Fund Charitable Trust, the Kid’s Fund, BMC Committee on Residents and Interns Quality Improvement grant, American Academy of Pediatrics Community Access to Child Health grant, Digital Federal Credit Union, Deloitte, and several generous individuals committed to improving child health. Ms Wenren was supported by BMC Pediatrics Child Health Advocacy Program.

Thank you to the administration at BMC who supported the implementation of this innovative project; to all of the clinic providers, staff, and residents without whom this project would not have been possible; and most importantly, to our patients, who trusted us with their precious time and financial information.

1
Renwick
T
,
Fox
L
;
U.S. Census Bureau
. The Supplemental Poverty Measure: 2015. Current population reports, series P60-258. 2016. Available at: https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-258.pdf. Accessed March 4, 2017
2
Moore
KA
,
Redd
Z
,
Burkhauser
M
,
Mbwana
K
,
Collins
A
;
Child Trends
. Children in poverty: trends, consequences, and policy options. 2002. Available at: www.hispanicresearchcenter.org/wp-content/uploads/2013/11/2009-11ChildreninPoverty.pdf. Accessed June 6, 2014
3
Chaudry
A
,
Wimer
C
,
Macartney
S
, et al;
US Department of Health and Human Services
. Poverty in the United States: 50-year trends and safety net impacts. 2016. Available at: https://aspe.hhs.gov/system/files/pdf/154286/50YearTrends.pdf. Accessed September 11, 2017
4
Center for Budget and Policy Priorities
. Policy basics: the earned income tax credit. 2016. Available at: www.cbpp.org/research/federal-tax/policy-basics-the-earned-income-tax-credit. Accessed December 19, 2016
5
US Internal Revenue Service
. EITC fast facts. 2017. Available at: https://www.eitc.irs.gov/partner-toolkit/basic-marketing-communication-materials/eitc-fast-facts/eitc-fast-facts. Accessed October 1, 2017
6
Weinstein
P
,
Patten
B
;
The Progressive Policy Institute
. The price of paying taxes II: how paid tax preparer fees are diminishing the earned income tax credit (EITC). 2016. Available at: www.progressivepolicy.org/wp-content/uploads/2016/04/2016.04-Weinstein_Patten_The-Price-of-Paying-Takes-II.pdf. Accessed December 16, 2016
7
Chetty
R
,
Friedman
JN
,
Saez
E
.
Using Differences in Knowledge Across Neighborhoods to Uncover the Impacts of the EITC on Earnings
. Working Paper 18232.
Cambridge, MA
:
National Bureau of Economic Research
;
2012
8
Rehkopf
DH
,
Strully
KW
,
Dow
WH
.
The short-term impacts of earned income tax credit disbursement on health.
Int J Epidemiol
.
2014
;
43
(
6
):
1884
1894
9
The effect of the earned income tax credit on infant health.
Natl Bur Econ Res Bull Aging Health
.
2012
;(
3
):
2
10
Averett
S
,
Wang
Y
.
The effects of earned income tax credit payment expansion on maternal smoking.
Health Econ
.
2013
;
22
(
11
):
1344
1359
11
Strully
KW
,
Rehkopf
DH
,
Xuan
Z
.
Effects of prenatal poverty on infant health: state earned income tax credits and birth weight.
Am Sociol Rev
.
2010
;
75
(
4
):
534
562
[PubMed]
12
Arno
PS
,
Sohler
N
,
Viola
D
,
Schechter
C
.
Bringing health and social policy together: The case of the earned income tax credit
.
J Public Health Policy
.
2009
;
30
(
2
):
198
207
[PubMed]
13
Hamad
R
,
Rehkopf
DH
.
Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit.
Paediatr Perinat Epidemiol
.
2015
;
29
(
5
):
444
452
14
Dahl
M
,
DeLeire
T
,
Schwabish
J
.
Stepping stone or dead end? The effect of the EITC on earnings growth.
Natl Tax J
.
2009
;
62
(
2
):
329
346
15
Milligan
K
,
Stabile
M
.
Do Child Tax Benefits Affect the Wellbeing of Children? Evidence From Canadian Child Benefit Expansions (NBER Working Paper No. 14264)
.
Cambridge, MA
:
National Bureau of Economic Research
;
2008
16
Maxfield
M
. The effects of the earned income tax credit on child achievement and long-term educational attainment. Michigan State University: Job Market Paper. 2013. Available at: http://econ.msu.edu/seminars/docs/20131114% 20Maxfield% 20EITC% 20Child% 20Education.pdf. Accessed March 3, 2015
17
Chetty
R
,
Friedman
JN
,
Rockoff
J
;
Internal Revenue Service
. New evidence on the long-term impacts of tax credits. Statistics of income paper series. 2011. Available at: www.irs.gov/pub/irs-soi/11rpchettyfriedmanrockoff.pdf. Accessed April 12, 2015
18
Dahl
GB
,
Lochner
L
.
The impact of family income on child achievement: evidence from the earned income tax credit.
Am Econ Rev
.
2012
;
102
(
5
):
1927
1956
19
Ziol-Guest
KM
,
Duncan
GJ
,
Kalil
A
,
Boyce
WT
.
Early childhood poverty, immune-mediated disease processes, and adult productivity.
Proc Natl Acad Sci USA
.
2012
;
109
(
suppl 2
):
17289
17293
20
Markowitz
S
,
Komro
KA
,
Livingston
MD
,
Lenhart
O
,
Wagenaar
AC
.
Effects of state-level earned income tax credit laws in the U.S. on maternal health behaviors and infant health outcomes.
Soc Sci Med
.
2017
;
194
:
67
75
[PubMed]
21
Council on Community Pediatrics
.
Poverty and child health in the United States.
Pediatrics
.
2016
;
137
(
4
):
e20160339
22
Aber
L
.
School Reform & Beyond – Improving Educational Outcomes
.
Vancouver, BC
:
Pediatric Academic Societies Platform Presentation
;
2014
23
Klass
P
.
Saving tiny tim–pediatrics and childhood poverty in the United States.
N Engl J Med
.
2016
;
374
(
23
):
2201
2205
24
Marr
C
,
Huang
CC
,
Sherman
A
,
DeBot
B
;
Center for Budget and Policy Priorities
. EITC and child tax credit promote work, reduce poverty, and support children’s development, research finds. 2015. Available at: https://www.cbpp.org/research/federal-tax/eitc-and-child-tax-credit-promote-work-reduce-poverty-and-support-childrens. Accessed December 28, 2017
25
Sherman
A
,
Trisi
D
,
Parrott
S
;
Center for Budget and Policy Priorities
. Various supports for low-income families reduce poverty and have long-term positive effects on families and children. 2013. Available at: https://www.cbpp.org/research/various-supports-for-low-income-families-reduce-poverty-and-have-long-term-positive-effects#_ftn3. Accessed December 28, 2017
26
Shanks
T
,
Danziger
SK
.
Antipoverty policies and programs for families and children
. In:
Jenson
J
,
Fraser
M
, eds.
Social Policy for Children and Families: A Risk and Resilience Perspective
, 3rd ed.
Thousand Oaks, CA
:
Sage Publications, Inc
;
2016
27
Hoynes
HW
,
Patel
AJ
. Effective policy for reducing inequality? The earned income tax credit and the distribution of income. NBER working paper No. 21340. 2015. Available at: www.nber.org/papers/w21340.pdf. Accessed December 28, 2017
28
Komro
KA
,
Flay
BR
,
Biglan
A
;
Promise Neighborhoods Research Consortium
.
Creating nurturing environments: a science-based framework for promoting child health and development within high-poverty neighborhoods.
Clin Child Fam Psychol Rev
.
2011
;
14
(
2
):
111
134
29
Brownell
MD
,
Chartier
MJ
,
Nickel
NC
, et al
.
Unconditional prenatal income supplement and birth outcomes.
Pediatrics
.
2016
;
137
(
6
):
e20152992
30
US Internal Revenue Service
. FY 2016 stakeholder partnerships, education and communication (SPEC) quality statistical sample (QSS) review results. 2016. Available at: https://www.irs.gov/pub/irs-utl/qss-review-results.pdf. Accessed September 5, 2017
31
US Internal Revenue Service
. Compliance estimates for the earned income tax credit claimed on 2006-2008 returns. Publication 5162 (8-2014) Catalog Number 66766H. 2014. Available at: https://www.irs.gov/pub/irssoi/EITCComplianceStudyTY2006-2008.pdf. Accessed September 22, 2017
32
Zuckerman
B
.
Growing up poor: a pediatric response.
Acad Pediatr
.
2014
;
14
(
5
):
431
435
33
Garg
A
,
Toy
S
,
Tripodis
Y
,
Silverstein
M
,
Freeman
E
.
Addressing social determinants of health at well child care visits: a cluster RCT.
Pediatrics
.
2015
;
135
(
2
). Available at: www.pediatrics.org/cgi/content/full/135/2/e296
34
Berkowitz
SA
,
Hulberg
AC
,
Standish
S
,
Reznor
G
,
Atlas
SJ
.
Addressing unmet basic resource needs as part of chronic cardiometabolic disease management.
JAMA Intern Med
.
2017
;
177
(
2
):
244
252
35
Gottlieb
LM
,
Hessler
D
,
Long
D
, et al
.
Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial.
JAMA Pediatr
.
2016
;
170
(
11
):
e162521
36
Halpern-Meekin
S
,
Edin
K
,
Tach
L
,
Sykes
J
.
It’s Not Like I’m Poor: How Working Families Make Ends Meet in a Post-Welfare World
.
University of California Press
;
2015
37
US Bureau of Labor Statistics
. Employment characteristics of families- 2016. USDL-17-0444. 2017. Available at: https://www.bls.gov/news.release/pdf/famee.pdf. Accessed October 1, 2017

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data