When the Cards are Stacked Against You: A Conversation with Pediatrician, Professor, and Entrepreneur Dr. Michael Hole

Qualities of life that most of us take for granted—clean air and water, a safe environment, access to healthy foods, and others—are the same qualities that deeply affect the health of low-income Americans. And when you’re a kid, you have little control over the quality of air you get to breathe or the foods you are given to eat. But it’s this exact environment that can shape your future. For the 1 in 7 children born into poverty each year in America, the wealthiest nation on Earth, the cards are stacked against them at no fault of their own. I had the privilege of speaking with Dr. Michael Hole—a pediatrician, health policy professor at UT Austin, and entrepreneur—about the work he is doing to lift children and families out of poverty. In 2016, Dr. Hole was named in Forbes’ “30 under 30,” and in 2019, Presidents Bill Clinton and George W. Bush named Dr. Hole a Presidential Leadership Scholar. 

If you’re in New York City, and you were to walk from the Upper East Side to East Harlem just a few blocks away, your short trip would cover a difference in life expectancy of 18 years. Same city, different world. The life expectancy across these two neighborhoods is not particularly unique. Similar and more drastic trends can be found in other major cities across the country, including Washington D.C., Chicago, and New Orleans. It’s a perfect example of how much your environment affects your health, and it’s these vulnerable populations that Dr. Hole treats. The families that Dr. Hole cares for are almost always without insurance, almost always experiencing poverty, and are often experiencing homelessness. When I asked Dr. Hole about social determinants of health, such as environment and income, he said, “Too many of my patients’ families face impossible decisions, like using their limited cash to fill a prescription or buy groceries. So much of my work is about connecting families to community resources and finding ways to get more money in their pockets so they can meet all their basic needs.” He included that although doctors have to know how to diagnose and treat diseases, “medical school curricula should include training in community engagement and how to form strategic partnerships with local service agencies tackling problems like hunger and homelessness. Only a fraction of people’s health is determined by the medical care they receive, so future physicians, regardless of specialty, must be equipped with the skills and networks they’ll need to address poverty and other social ills impacting their patients’ health.”

Dr. Hole has gone far beyond writing prescriptions to help his patients. He co-founded StreetCred, a national nonprofit helping low-income families file taxes, claim refunds, set up savings accounts, and build budgets, credit, and wealth while they wait in a trusted, frequent space: hospitals and clinics. Since its founding in 2016, StreetCred has put over $8.5 million in tax credits in the pockets of low-income families. Integrating tax-preparation with healthcare may appear opaque, but Dr. Hole shared how the two are interrelated, saying “When you have children, you come to the doctor’s office a lot, especially when they are little, even when they’re healthy. And the doctor’s office is a place you trust. Doctors ask about sensitive topics all the time: sex, drugs, mental health. So it’s a place to have hard conversations about finances, too—and to connect people with financial resources. Money matters to people’s health, and as such, I’m on a mission to make sure America’s health systems act like it.”

Dr. Hole discussed how important it is for low-income families to take advantage of the Earned Income Tax Credit (EITC). The EITC is the nation’s largest federal anti-poverty program, and it provides tax credits to low-income families based primarily on their income and the number of children they support. This money can be invaluable to low-income families, and as Dr. Hole says, “The program is well-studied. We know that when low-income families get this money, good things happen for their health, children’s education, and their future financial outcomes. For example, pregnant women who receive the EITC deliver babies with higher birth weights. Mothers who get the money have less stress, and children in families who receive the EITC graduate high school at higher rates.  These are remarkably good things, but the EITC goes largely unclaimed. 20% of the families who are eligible for it do not take advantage of it every year.” StreetCred ensures more families get the money they need. 

In talking about the impact of StreetCred, Dr. Hole shared that their very first ‘client’ was a “grandmother with a toddler who used the extra money to buy him a winter coat, which was a luxury in her mind.” Millions of children are lifted out of poverty every year thanks to the EITC, and it’s critical to ensure low-income families know the credit exists and know how to take advantage of it. Dr. Hole concluded by saying, “At the core of nearly any social problem—food insecurity, housing insecurity, etc.—is financial insecurity. As such, StreetCred is addressing social issues at their core. And that’s important because wealth is health.” 

Like the earned income tax credit, the Supplemental Nutrition Assistance Program (SNAP) is a lifeline for low-income families and a critical program for lifting children out of poverty. SNAP provides money for food to low-income families, and the children impacted by SNAP are significantly more likely to graduate high school and experience far better health outcomes, including lower rates of obesity later in life. About 17% of children live in households that receive SNAP benefits. In the realm of food insecurity, I asked Dr. Hole about a service called Good Apple, for which he serves as the Founding Advisor. Good Apple is focused on fighting food insecurity, and the organization partners with farmers, food pantries, transportation companies, philanthropists, nonprofits, medical clinics, and universities to deliver healthy foods, such as fresh fruits and vegetables, directly to the doorsteps of families facing food insecurity. Dr. Hole told me that “Food shortage isn’t the problem. We have food banks, food pantries, government programs like SNAP, and a whole host of other food services available to people facing food insecurity. But that doesn’t mean people have easy access to those services and places. Transportation is a huge barrier, and it got even worse amid the COVID-19 pandemic when traveling in public meant increased risk of infection. What’s worse: federal programs don’t subsidize food delivery services. So, while you and I can order groceries online and have them delivered to our doorsteps—that’s a big privilege. Good Apple is working to close that gap.”

A kid’s health is impacted by where they live, what they are fed, how much income their parents earn, the color of their skin, and several other social factors. We know that multiple, compounding social problems early in life can lead to really poor health outcomes later in life. Many of the federal programs currently in place, such as SNAP, are contentious, and proposed government programs like universal basic income instantly create debate. Welfare legislation can look expensive upfront, but as Dr. Hole says, early investments in children’s health can “save our very expensive healthcare system a lot of money.” It’s important for us to dive deep into the best strategies to lift American children out of poverty because investing in our children’s health is investing in the future of America.