Living in poverty often entails living under stressful, harsh living conditions. As a result of these stressful conditions, poor people may experience frailty, disability, dementia, and death at a much earlier age than better-off people. Most of the societal burden of disease and much of Medicare's costs rest in lower-income communities. Therefore, when the Affordable Care Act was developed, the US government began to offer incentives for providers to go beyond providing medical care, and to fund programs that could address social conditions within the communities that they serve. Government insurers have invested billions in social programs early in life with the hope of improving population health later in life, thereby reducing Medicare costs. Still, little is known about whether social programs can reverse the health risks that are associated with poverty, particularly when applied to adults. After years of exposure to adversity, brain structures involved in the regulation of blood sugar, blood pressure, and memory atrophy. One such aspect of brain function is executive function?one's ability to initiate tasks, plan, and remain goal-oriented. Executive function is critical for starting and keeping a healthy diet, exercise regimen, or a job. Weak executive function can therefore create a poverty trap, in which hardship begets more hardship. Neurological damage associated with poverty is believed to be partially reversible. But executive function highlights the ?chicken and the egg? problem associated with measuring the health effects of poverty; people can be poor because they have weak executive function or they can have weak executive function arising from the overwhelming stress of living in poverty. One way to be sure that it is possible to reverse the damage that poverty might inflict on the brain is to conduct an experiment that will both reduce poverty and improve executive function. As a first step, we ran a multicenter randomized controlled trial (RCT) called Work Rewards. Work Rewards proved that it was possible to lift unemployed housing recipients out of poverty. We build on Work Rewards successes and add an intensive, 3-year long executive function training program. This second RCT, called MyGoals, is already funded. However, there is no long- term survey planned for health data collection. We propose to add a longer-term follow-up survey that includes medical examination data to test for obesity and hypertension, biomarker data to test for diabetes and stress, and to add cognitive testing for changes in executive functioning. Assessing these dimensions will provide evidence on whether social programs have the potential to break the association between poverty, unhealthy aging, and cognitive decline, informing scale-up for wider implementation of poverty-reduction programs.
Columbia University has partnered with the research firm MDRC to conduct a multicenter randomized controlled trial (RCT). This RCT examines long-term health, cognition, and aging outcomes associated with a novel and innovative social policy that randomizes unemployed public housing recipients to either receive a package of work incentives coupled with an executive function intervention (treatment group) or to receive public housing alone (control group). The outcomes of this trial will inform scale-up of effective programs that promote healthy aging by reducing poverty, thereby reducing government health expenditures.
