By Sara E. Abiola and Zohn Rosen
Full recovery from the COVID-19 pandemic in the U.S. will require new policy that promotes equity and streamlines access to social services while supporting small businesses
Unprecedented job loss due to COVID-19 has led to an economic crisis for families of all backgrounds and income levels.
Current health and social services programs are ill-equipped to handle this need. Moreover, long-standing racial health inequities and the stigma associated with using social services will persist in the absence of significant systems-level change.
The pandemic has revealed a population with limited access to preventive healthcare suffering from noncommunicable diseases such as obesity and diabetes. These individual-level health outcomes are largely determined by social and economic factors.
Where people are born, grow, live, and work has a greater impact on health and well-being than healthcare. These conditions–the social determinants of health (SDoH)–are shaped by distributions of money, power, and resources and are largely responsible for unfair and avoidable differences in health status observed between racial and ethnic groups. Unequal access to quality education, food, housing, employment, and clean air are key determinants.
Policy transformation informed by SDoH research may help reverse current trends. Greater flexibility and efficiency in existing federal social safety net programs is one such transformation. The Social Services, Technology, and Administrative Restructuring Initiative (“SSTAR Initiative”), developed in our capacity as scholars in health policy and management at Columbia University, would incorporate five sectors–employment, food, housing, education and transportation–into a single entitlement program for all Americans. The SSTAR Initiative is rooted in the knowledge that healthier populations with lower levels of inequality contribute to a stronger economy.
Core principles for social safety net policy post-COVID: efficient, flexible, essential, universal
The SSTAR Initiative would create a single agency to manage eligibility determinations and distribution of benefits. Currently, multiple applications and independent verification processes significantly limit program access. Elimination of duplicative paperwork and automated eligibility determinations across programs would be a top priority. In its initial form, the agency would aggregate funds from all available programs into a single account.
Second, funds would be flexible, available for use however households deem most pressing. Current programs require participants to use funds in specific ways that may not meet shifting family needs. For example, SNAP benefits can only be used to purchase food and cannot be repurposed to cover rent. The SSTAR Initiative would allow every person to allocate funds according to specific need–families may prioritize housing assistance and may elect to use most or all of their monthly allotment to cover that expense.
Third, funds would be applied to a wider range of goods and services that are essential to promote health. Many of these services could be provided through existing small businesses. For example, funds could be used to pay for car repairs- this ensures that people can get to work while providing a new source of revenue for the local auto shop. Table 1 is an illustrative list of purchases covered under the initiative.
Table 1. Essential goods and services covered by the SSTAR Initiative 
Finally, all Americans would receive a StarCard – a simple and efficient means to access and distribute stimulus or unemployment funds, means-tested support like food stamps, and support for education or job training programs. Universal enrollment could help remove the stigma associated with receiving government support. Each individual would be able to make use of the StarCard, or not. The StarCard creates a platform to deliver funds to specific groups in a more efficient manner. The card would operate much like a debit card linked to a central account and administered by third parties- such as participating banks- and backed by a block-chain verification system to minimize the risk of fraud.
Promoting small businesses to promote health
At every stage of development businesses rooted in the community could provide goods or services covered by the StarCard. For example, individuals with small children may use the majority of their benefit to cover childcare in early years and education or summer programs as the child ages. Private instructors, nutrition coaches, childcare providers, and even small landlords could be partially supported by SSTAR funds. This model introduces competition between existing businesses, as StarCard funds could be used at any retail location that accepts debit or credit cards. Businesses that applied to be designated as community-based organizations would be rewarded through supplemented discounts to consumers.
Conclusion
The US will suffer in the face of each new public health challenge unless we adopt a truly innovative approach to promote equity, financial stability, and population health over the long-term.
We must create a system that ensures access to essential resources for more Americans. Effectively, the SSTAR Initiative would restructure our fragmented safety net into a system that supports all of us.
To be sure, the initiative is not a panacea for all problems on the post-pandemic landscape. However, a program tailored to current social and economic realities is a significant step forward.
Sara E. Abiola, PhD, JD is an Assistant Professor of Health Policy & Management, Columbia University and Co-Director of the Better Health Systems Lab.
Zohn Rosen, PhD is a Lecturer in the Department of Health Policy and Management, Columbia University.
