Increasing Access to Antipoverty Tax Credits Through a Medical Financial Partnership

Poverty is a strong predictor of poor mental and physical health in childhood and throughout life.^1,2 Antipoverty tax policies in the United States like the Earned Income Tax Credit (EITC) and the Child Tax Credit (CTC) lift millions of children out of poverty each year and encourage positive development.³ The EITC, first introduced in 1975, lifted more than 5 million people out of poverty in 2018, more than half of whom were children.³ The Child Tax Credit, introduced in 1997, provides additional funds to families to offset childcare costs. Both the EITC and CTC were temporarily expanded in the American Recovery Plan Act (ARPA),⁴ and the increased amounts were credited with reducing child poverty to a historic low in 2021.⁵ Increased amounts of the EITC and CTC are associated with reduced child maltreatment,^6,7 infant mortality,⁸ mental health problems,^9–11 and maternal substance use.^12,13 

Unfortunately, approximately 20% of taxpayers who are eligible for the EITC do not participate, leaving millions in unclaimed tax credits on the table each year.¹⁴ Cross-sector and community-based efforts are critically needed to encourage uptake of the EITC and CTC. The need for community-level engagement was even more apparent with the ARPA policy changes that temporarily altered the EITC and CTC. Ensuring that eligible tax filers were aware of these changes required outreach from trusted sources. For example, tax filers with child dependents who had not filed taxes previously due to no or very low income were eligible for the CTC for the first time and needed to register with the IRS or file their 2021 taxes to receive these credits.

Pediatric health care systems were well positioned to share this information and leverage this antipoverty intervention to address a wide range of health outcomes, such as those targeted by the Pediatric Vital Signs project. The purpose of this case study is to describe a large-scale effort to expand awareness of and access to the EITC/CTC for low-income families in the Columbus, Ohio metropolitan area over a 3-year period that coincided with the COVID-19 pandemic. Although prior studies have summarized efforts to colocate tax filing services in health care settings,^15–18 these efforts have not coordinated with external community-based organizations specifically focused on maternal child health or harnessed large-scale marketing campaigns to increase community participation. We also describe how this program evolved during the height of the COVID-19 pandemic and adapted to ARPA policy changes. This example expands on what has been described previously for medical-financial partnerships (MFPs) in pediatric health care settings,^16,18 by increasing the scale at which these services were provided, working with key community partners already targeting their services toward zip codes experiencing the most disparate maternal and infant health outcomes, and developing a sustainability plan. We built on these partnerships by working with the national Volunteer Income Tax Assistance (VITA) program to offer new tax sites, in addition to what was already offered in the community prior to this expansion, in both health care and community settings.

This multi-sector partnership launched in fall 2020 with the explicit goal of linking an existing volunteer tax preparation service with the infant mortality prevention collaborative in one Midwestern city. We report on experiences of implementing this program through spring 2023. An operations leadership team began meeting monthly in 2020 to plan outreach and education aimed at promoting uptake of the EITC/CTC tax credits and awareness of free tax filing services. These efforts were led by Nationwide Children’s Hospital (NCH), in collaboration with community-based organizations. Tax site locations, mostly in NCH primary care clinics (3 clinics, 2 community sites), were targeted in the most impoverished zip codes that experienced the highest infant mortality rates. Eligibility for the expanded free services were 1) having total household income <$65 000 and 2) having children in the household.

A project team of researchers and hospital staff from NCH led program implementation. A dedicated program coordinator and outreach specialist led preparation activities before tax filing season, engaged with community service providers, and organized and operated 5 free tax filing sites. The program coordinator was certified in tax preparation and oversaw recruitment and supervision of volunteers and volunteer staffing at tax clinics. The outreach specialist oversaw appointment intake and served as the “front door” for the project, when necessary, at tax sites. The program coordinator led on-site trainings for community service providers to share information on referrals and appointment scheduling.

NCH chose not to offer independent services only at health care system sites but rather to partner with the existing regional voluntary income tax preparation collaborative. This decision was made to ensure consistency in training and marketing, support sustainability, make efficient use of resources, and support access by staff and neighbors who were not direct patients. United Way of Central Ohio (UWCO) is the recipient of the IRS’ VITA grant for central Ohio, overseeing operations of 20 VITA sites across Franklin County and surrounding counties. UWCO seeks to create pathways for tax filers to access free tax filing services and works with other partners, such as NCH, to create tax filing opportunities. UWCO’s Tax Time initiative (the name of the local collaborative group) was the financial services partner and provided access to tax software and tax preparation training materials for NCH volunteers. The UWCO Tax Time program manager and staff met regularly with the NCH team and were available for consultation during initial program launch and ongoing implementation. They also provided valuable input on all joint marketing materials and public announcements.

CelebrateOne is a cross-sector, countywide partnership focused on maternal and child health, which includes health care institutions, public health officials, elected representatives, and neighborhood residents. Their work includes managing a community health worker program that connects women in targeted neighborhoods to health and social services, focusing on areas experiencing high rates of poverty and infant mortality. Physicians CareConnection (PCC) StepOne is a central call-in system for pregnant women to schedule prenatal appointments and provides referrals to other social services, serving close to 3500 women each year. These partnerships allowed the program to cast a wide net to potentially eligible families, including some first-time parents, to increase awareness of the importance of tax filing and availability of free services. CelebrateOne and PCC StepOne worked with the NCH team on referral pathways for their clients and gave feedback on marketing materials.

The NCH marketing team guided the overall outreach strategy with the goal of increasing awareness of the EITC and use of free tax filing services. Each year, a comprehensive marketing campaign incorporated multiple channels, which included grassroots community outreach, targeted digital advertising, partner organization outreach in targeted neighborhoods, and internal (within NCH) advertisements. A public website was developed to serve as a hub for all marketing messages (614FileFree.org). The website hosted informational videos on tax filing, an FAQ page, and an appointment scheduling tool. The website and materials were continuously updated throughout the project and included supplemental information regarding the ARPA changes to the CTC. A strength of the program was that this website and marketing tools were already in place when the CTC was introduced.

Targeted digital marketing included social media platforms (Instagram, Facebook) and web search engine advertisements for specific key word searches (eg, “free tax filing”), which placed the website at the top of search results. In year 1, the program experimented with using radio (Spotify and Pandora). In years 2 and 3, marketing messaging was launched in phases, with Phase 1 (early winter) focused on sharing information regarding the importance of tax filing and common questions. Phase 2 (mid-winter) shifted focus on availability of free tax filing services and appointments. Print advertisements were posted at key community locations (eg, public libraries, recreation centers, primary care offices, salons, or day cares) and community events and translated (Spanish, Somali, and Nepali). In addition, each winter, postcards were mailed to residents of targeted zip codes, referencing closest available appointment sites. All print materials included QR codes allowing individuals to quickly navigate to the website for more information.

The program coordinator and outreach specialist met with partner organizations in the fall prior to each tax season. They hosted a luncheon for staff members from PCC StepOne and CelebrateOne during which they gave brief trainings on the EITC/CTC, importance of tax filing for clients, and benefits of the EITC/CTC for children and families, and how to refer clients to free tax filing services. A video training with this information was also shared widely within these organizations to reach all service providers.

One of the main goals was to improve accessibility of free tax services. Additional VITA sites were opened in locations where families were already accessing health care or social services in targeted neighborhoods, which included 5 locations across 5 different zip codes. At the NCH primary care sites, the availability of interpretation services through the on-site interpreter call-in service allowed tax services to be offered to non–English-speaking tax filers. The program also developed “pop-up” tax services sites including a large “Super Saturday” in the third year, cohosted by UWCO.

The tax sites specifically targeted lower-income women who were pregnant, or had young children, and other socioeconomically disadvantaged tax filers from neighborhoods with high infant mortality. The average gross income did not differ markedly over time and, for a household size of 4, was well below the federal poverty line (Table 1). The majority of those served identified as Black or African American and were filing as the head of household. In total, 1522 taxes were filed over the 3-year period. In years 2 and 3, 6% (32/512) and 8% (40/532) of tax filers filed multiple years of tax returns at their appointments, indicating that they had not filed taxes in at least the previous year (data not available for year 1).

During the tax filing season in 2021, the local community was in a winter wave of COVID-19 cases. However, the NCH pediatric primary care clinics were operating at close to regular patient visit volumes throughout this period and were well positioned to deliver in-person tax services at their locations. These sites had built-in COVID-19 safety protocols, making it possible to operate in-person services while other UWCO sites operated services virtually. In the first year, these new sites filed 469 taxes (Table 1), which provided a critical safety net for many filers who had substantial barriers to accessing the UWCO virtual tax filing service. For example, many clients did not have the ability to upload tax preparation materials to the secure site, lacked reliable internet, or did not have regular access to devices for internet-based services.

Over the course of the project, the tax filing volume increased, including increases in the number of clients served (from 469 to 531) and in the total amounts of federal and state tax returns (from $1 021 835 to $1 062 757) (Table 2). Of note, the program also served many clients who were not ultimately required to file taxes due to no or low income (n = 32 in year 3), which brought the total number of individuals served to at least 560 in year 3. The size of the total state and federal tax credit amounts increased sharply in the second year (tax year 2021) due to the ARPA changes that increased tax credit amounts markedly but reverted to the prior amounts after the policy ended.

Marketing data were reviewed each year and informed next-year planning. The campaign experimented with advertisements via Pandora and Spotify, which garnered a lot of “impressions” (or views of the advertisement) but not large numbers of website clicks for further information or appointments. Radio was abandoned in subsequent years. Banners in community locations, which included QR codes, did not yield large numbers of hits to the website but may have increased awareness. Postcards and refrigerator magnets were mailed to more than 15 000 residents in targeted zip codes, but data on effects for these modalities are not available. Media outlets were also provided with press releases to increase awareness of the Super Saturday event in year 3.

Social media and search engine advertisements were the biggest drivers of traffic to the website to make appointments. Community partners were also provided with social media messaging for their own platforms. As a result of evolving marketing strategies, website traffic increased substantially from year 2 to year 3, from 5600 page views in year 2 to 11 700 in year 3 (109% increase from year 2) and from 4945 total users to 5900 total users (19.3% increase) in the same period. Importantly, the program was able to track the source of websites users, and many landed on the page through directly entering the URL, suggesting name recognition, repeat users, and effectiveness of multilayered advertising approaches.

In year 3, NCH and UWCO partnered to host a Super Saturday event in mid-February 2023 and prepared 85 tax returns, with a total of $125 279 in total federal refunds, which included $43 410 in total EITC and $38 121 in total CTC. The event provided free childcare and hosted booths from local community-based organizations and financial services organizations. These total tax filings and return amounts were in addition to those listed in Table 2.

Launching a multiyear initiative to promote awareness of and access to free tax filing services yielded numerous lessons learned that could assist other organizations considering similar programming. In total, 1522 tax returns were filed, resulting in $3 496 700 in total federal and state tax credits. Moreover, at an average cost of $200 to $300 per tax filing at for-profit companies, offering free services saved the community at least $304 400 in fees. We do not know how many of the tax filers we served used for-profit companies for tax filing in previous years. Nevertheless, the filers we served at our sites did not have to pay fees and lose a portion of their return in the year we served them. The successful launch of these services provides a blueprint for establishing and growing a program within the context of pediatric primary care and a strategy for encouraging awareness of services through an organized marketing campaign and partnerships with community-based organizations focused on maternal child health.

The marketing campaign provides an example of how messaging could be used to successfully spread awareness of available tax credits and free tax filing services. This approach might be more feasible for large organizations, such as health care organizations, that are interested in spreading the word about services but do not have the time-intensive resources available for a “boots on the ground” approach to direct outreach. The program successfully filled all appointments within weeks of opening appointments. Through the Super Saturday event, the program reached additional clients. Nevertheless, the ease of appointment scheduling, while considerably reducing staff workload for scheduling volunteer tax preparation services, can also create its own challenges and lead to high “no show” rates for appointments. In year 3, there were 1325 scheduled appointments, of which 113 were canceled and 238 were “no show,” but these slots could often be filled with walk-in appointments. The program learned that if scheduling is allowed too far in advance, clients were more likely to miss appointments. The scheduling tool could be further supported through appointment reminders and only scheduling out appointments 1 to 2 weeks in advance.

One of the main challenges for our efforts and for other programs is confronting preexisting tax filing habits with for-profit tax filing services. These services often capitalize on the large tax credit amounts available to eligible families. In exchange for “early” access to tax credit amounts, companies charge fees for tax filing or a percentage of the tax credit amount. These services may target their marketing or locations to specific neighborhoods. For other free tax services providers who hope to expand free services in these communities, it is a difficult position to be in. On the one hand, families may have come to rely on receiving access to tax credit amounts as early as possible. On the other hand, they may be paying large sums of money for tax filing that is unnecessary and eats into their available tax credit amounts. The growth in our program over time suggests that early marketing in advance of when these services start could increase use of available free tax filing services.

In-person tax services are still sought after by the community we served. Even though the digital divide is shrinking, there are many families that prefer a trusted advisor and in-person services or may not have reliable Wi-Fi or a smartphone on which to participate in virtual services. Fortunately, during the COVID-19 pandemic, we were able to continue to provide in-person tax filing services. In many ways, the safety protocols available through primary care sites and community trust allowed us to fill in the gap where other community organizations were challenged. Unfortunately, demand for these services outstrips supply, and each year, appointment scheduling had to be closed early due to filling up all available time slots. More work is needed to understand how to recruit and retain volunteers and assist them with overcoming the hurdles to becoming certified so that there is an adequate supply of volunteers to further expand services.

Each year, the program learned new ways to optimize marketing data through specific tracking of how and where individuals landed on the website. When the website was built, it was built with the principles of balancing educational information in a quick and easy-to-use manner, along with assisting with quick appointment scheduling. From web statistics, we know people were easily able to consume information and find what they needed. However, we have also learned about the power of a quick and easy name to remember. A significant portion of web traffic each year came from direct traffic, meaning users typed “614filefree.org” in their browser, and we have found they also searched “614FileFree.” This means they likely had awareness of the site through flyers, postcards, and ads. Both name recognition and providing a high-quality service where customers have a good experience with the free tax filing service and want to come back, year after year, are critical to sustaining the reputation and interest within the community.

Moving forward, the program will be sustained through a variety of funding mechanisms, including the hospital’s commitment to direct hires for managing the program in future years. In addition, this program is being expanded by Partners for Kids, a Medicaid accountable care organization, into 2 additional counties in rural Ohio, Licking and Muskingum, as a first step toward coverage of Ohio Appalachian counties. The 2023 tax filing season was the first year of providing initial rural supports, including marketing materials, to launch in Muskingum County. More than 350 Muskingum tax returns were filed, which brings our total number to more than 950 assisted tax returns in the 2023 tax filing season.

As the tax filing program continues to grow, this also creates opportunities to integrate other financial services such as financial coaching, savings or debt management, or homeownership education. It will be important moving forward to integrate these tax services into other financial education and programming. However, at any scale, programs must maintain high-quality customer service so that tax filers leave with a good experience, spread the word to neighbors and friends, and continue to want to use the service in the future. Ultimately, this is an example of an approach to address poverty, which could have a direct and lasting impact on health outcomes.

Health care institutions developing MFPs have numerous options for integrating services into their sites and care processes. Previously described MFPs have largely focused on financial services or education delivered to patients as part of their health care visits.^15–18 We chose to partner with an existing national program, the IRS VITA program, and its local “franchise” in central Ohio, the Tax Time collaborative, to directly address poverty and infant mortality among patients and their communities rather than start an independent service. This has allowed rapid startup, local goodwill, and quick expansion to other regional VITA sites like Muskingum County.

ARPA

American Recovery Plan Act

CTC

Child Tax Credit

EITC

Earned Income Tax Credit

MFP

medical-financial partnership

NCH

Nationwide Children’s Hospital

PCC

Physicians CareConnection

UWCO

United Way of Central Ohio

VITA

Volunteer Income Tax Assistance