From One Generation to the Next

The U.S. takes pride in being a land of opportunity, and Americans maintain the core belief that hard work and determination are rewarded. But, how level is the intergenerational playing field, and what factors underlie the intergenerational transmission of economic status and well-being? If we hope to reduce the transmission of poverty from one generation to the next through effective policy interventions, we need to know the answers.

Compared to most other high-income countries, the United States today has an unusually low level of intergenerational mobility. Successful parents tend to have successful children; their earnings typically are highly predictive of their children's income as adults. Research by American University economist Tom Hertz, among others, has shown that mobility from one generation to the next in the U.S. is now lower than in France, Germany, Canada, and the Scandinavian countries. Only the United Kingdom is less mobile than our own society. How can this be?

Education and race are among the variables that help predict mobility. So, too, is health. Poor health at birth is one key channel through which economic status and well-being is transmitted from parent to child. Again, compared to the nation's richest countries, the U.S. ranks at or near the very bottom in almost every measure of health: infant mortality, low birth weight, life expectancy, and more. Research has shown that black men in Harlem are more likely to die before 65 than men in Bangladesh. The main causes of death in poor black communities aren't only homicide, drug abuse, and AIDS, but a seemingly more benign litany that includes "unrelenting stress," cardiovascular disease, cancer, and untreated medical conditions.

Studies highlight early childhood as a critical period for brain development and for setting in place the structures that will shape future cognitive, social, emotional, and health outcomes. Limited parental resources, including child poverty and lack of health insurance, and its attendant stressors have the potential to shape the neurobiology of the developing child in powerful ways, which may lead directly to worse health later in life.

Let's take the case of low birth weight. A study I co-authored with Robert Schoeni finds that babies born too soon or small suffer significant detrimental effects. Low birth weight -- defined in medical convention as less than 5.5 pounds -- increases the probability of dropping out of high school by one-third, reduces later earnings by about 15 percent a year, and burdens people in their 30s and 40s with the health of someone who is 12 years older. Our study, the first to link birth weight with adult health and socioeconomic success using a full, representative sample of the U.S. population, provides a detailed look at how well-being and disadvantage are transmitted across generations within families.

The poor economic status of parents during pregnancy leads to worse birth outcomes. In turn, these negative birth outcomes have harmful effects on children's cognitive development, health, and educational attainment, and also on their health and economic status in adulthood. These effects then get passed down to the subsequent generation when the children, who are now adults, have their own children.

Not only does low income and lack of health insurance for parents increase the likelihood of poor birth outcomes, but the effects are cruelly compounded for their kids: The lack of health insurance intensifies the negative impact of low birth weight.

Intervene, But How?

Evidence like this is a report card that shows how the life chances of poor children are being undermined. Even more importantly, it is a challenge to do better. Being born at-risk does not have to be a life sentence for our children. The policy implication is that better access to health insurance and better prenatal care for low-income women may have significant effects on economic mobility. Policy measures can, and should, be designed to reduce the importance of these mechanisms if we wish to promote equality of economic opportunity.

There is the old adage that hereditary risk factors load the gun, but environmental risk factors pull the trigger. This suggests that intervening early -- and in ways that are based on the research evidence -- has the best chance of improving a child's health and well-being far into adulthood.

Reducing the incidence of low birth weight, for instance, is a far more cost-effective policy than relying only on high-tech neonatal care. Low birth weight infants account for a large and disproportionate share of public-health expenditures: More than one-third of the dollars spent in the U.S. on health care during the first year of life can be attributed to low birth weight, even though these infants account for less than 10 percent of all U.S. births.

We know, for example, that smoking during pregnancy doubles the risk of a low-weight birth. We also know at least one public policy can modify that risk: higher cigarette taxes, which have been proven to curb smoking among pregnant mothers, among others -- and to correlate to an almost immediate drop in the risk of low birth weight. Yet because only a minority of pregnant women smoke and the vast majority of low-weight births are to nonsmokers, even large cigarette-tax hikes have only a modest impact on aggregate infant health.

A more sweeping public-policy lever, of course, involves efforts to expand and promote the best possible prenatal care for the widest possible group of mothers. The evidence finds that women with more prenatal-care visits have children with lower rates of low-weight births and a host of other positive outcomes. Conversely, prenatal visits missed by at-risk mothers early in pregnancy have demonstrable negative effects. Findings on the impact of good prenatal care were a driving force behind recent expansions in the Medicaid program, and in the stated goals of the U.S. Public Health Service, as outlined in the federal government's Healthy People 2010 initiative.

The targeted Medicaid expansions of the late 1980s came at great cost to taxpayers, but had the potential to offset huge and costly long-term consequences associated with risky pregnancies. Just like in manufacturing, it costs a lot more to fix defects at the end of the assembly line than to do it right at the outset. Here too, though, the tremendous potential payoff of a wise policy intervention has its limits: Although Medicaid eligibility expansions over recent years have increased the percent of births paid for by Medicaid from 15 percent to 40 percent, many women still fail to obtain adequate prenatal care, enrolling in Medicaid at the point of birth rather than before. This pattern of delay means that Medicaid ends up sponsoring expensive treatment for gravely ill infants, rather than preventing their illnesses through adequate prenatal care.

Taken together, this research shows that more effective policy interventions to ameliorate the burden of disease and the economic cost to the health-care system are feasible. The economic drain may be reduced by greater investment in early life interventions, particularly those that decrease risks of low birth weight. This work can assist in shifting the goal from symptom amelioration to disease prevention. The seeds of vulnerability to chronic health conditions are planted early in life, possibly in utero.

The learning and aging processes begin at conception. The uneven distribution of educational attainment and health disparities linked to socioeconomic status may be ameliorated through policy initiatives that link quality early childhood care, preschool, and positive parenting in a seamless continuum with strengthened K-12 education.

Yet from a public-policy perspective, we have allowed a massive mismatch between the opportunity to positively influence an individual's healthy development during childhood -- when they are most malleable -- and the other public investments we make in education and health services into adulthood. U.S. health policy has traditionally been more rehabilitative in its approach to health promotion, as opposed to developing targeted programs that address socioeconomic dimensions of family and neighborhood environments, within which individual health differences may be better understood and more efficiently targeted. There are critical periods early in life that represent windows of opportunity to affect conditions that can have a profound impact on economic mobility patterns and health later in life. This understanding should guide policy-makers toward programs that build a bridge between childhood and early adulthood, especially for the poor, so that fewer individuals arrive at the doorstep of adulthood with accumulated -- and irreversible -- exposures.

There exists a gap between what we know about the earliest years of life and the public policies that support families with infants and toddlers in the U.S. There has been limited expansion of work supports in recent years, and even some retrenchment of supports such as the State Children's Health Insurance Program and child care -- policies clearly associated with helping the working poor get ahead. And as others in this special report argue forcefully, we must improve access to comprehensive early childhood services for expectant parents, babies, and toddlers at greatest risk. The earlier family support and educational enrichment are provided, the better the outcomes.

A policy based on evidence from research on the social determinants of health and that integrates income-support policies at various stages of life could do more than just make us healthier: It could also improve educational attainment, reduce income inequality, and promote economic growth. If we really want to reduce the economic and social costs of health disparities, poverty, and crime, then we must confront its early roots.

High Stakes

Behind the childhood poverty statistics is a face of impoverishment and the lost potential of our children. Being poor robs children of life chances, and sometimes their very lives. Those without the head start of family assets have a much steeper climb out of poverty. Social policy needs to ensure income sufficiency, while simultaneously increasing investments in the assets of the poor, so that they can take advantage of opportunities throughout their life course.

The seeds of failure in school are sometimes sown long before high-risk children enter school. If we do not face the challenge head-on to provide the highest quality compensatory programs for our neediest children in their earliest years, then we better prepare for the consequences later on. Our national commitment to equal opportunity and economic efficiency requires that we take these statistics seriously, gain a better understanding of the mechanisms at work, and pursue policies that will allow all Americans to reach their full, productive potential over a long and healthy life.