Free Tax Services in Pediatric Clinics

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.

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.

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.

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).

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).

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

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.