The African-American Maternal & Infant Mortality Crisis

How structural racism is killing black moms and babies; Trump’s proposal to artificially “reduce” the poverty rate by fudging the numbers; and an update on the nutrition assistance crisis in Puerto Rico. Subscribe to Off-Kilter on iTunes.

This week on Off-Kilter…. Happy Mother’s Day to all the moms out there. Meanwhile, Mother’s Day isn’t just a time for appreciating the mothers in our lives. It’s also a particularly somber holiday for many, considering that the U.S. has the highest maternal and infant mortality rates among comparable developed countries. As if that’s not bad enough, the survival rates for African American mothers and their babies are even worse. African-American women across the income spectrum and from all walks of life are dying from preventable pregnancy-related complications at three to four times the rate of non-Hispanic white women, while the death rate for black infants is twice that of infants born to non-Hispanic white mothers. Rebecca sits down with Jamila Taylor, a senior fellow and director of the Women’s Health and Rights project at the Center for American Progress, and the lead author on a new report laying out a framework for eliminating racial disparities in maternal and infant health by tackling the structural racism that’s killing black moms and babies.

Meanwhile, earlier this week the Trump administration announced a major new proposal to reduce the number of poor people in the U.S. But don’t get too excited… what they’re proposing wouldn’t actually boost anyone’s incomes. Rather, Trump is proposing to change the poverty measure used by the federal government to artificially “reduce” the poverty rate. So Rebecca brings back Jared Bernstein, a senior fellow at the Center on Budget and Policy Priorities and former chief economist to former Vice President Biden, to unpack what Trump’s proposing and what it would mean for low-income families.

Finally, Javier Balmaceda, senior analyst on Puerto Rico at the Center on Budget and Policy Priorities, joins to share an update on where things stand with Puerto Rico’s nutrition assistance crisis that’s left 1.4 million of the island’s residents hungry while Washington lawmakers play politics over a disaster package.

This week’s guests:

• Jamila Taylor, senior fellow and director of the Women’s Health and Rights Project, Center for American Progress
• Jared Bernstein, senior fellow, Center on Budget and Policy Priorities
• Javier Balmaceda, senior policy analyst on Puerto Rico, Center on Budget and Policy Priorities

For more on this week’s topics:

• Learn more about Trump’s move to redefine poverty in Jared’s tweet thread, this TalkPoverty explainer by Kate Gallagher Robbins, and this Washington Post piece by Helaine Olen
• … and then tell Trump what you think about his mathematical gaslighting by submitting a comment here (deadline: June 21)
• Dig into Jamila and colleagues’ report on Eliminating Racial Disparities in Maternal and Infant Mortality
• Read more from Javier on the nutrition crisis in Puerto Rico

This week’s transcript:

REBECCA VALLAS (HOST): Welcome to Off Kilter, the show about poverty, inequality, and everything they intersect with, powered by the Center for American Progress Action Fund. I’m Rebecca. This week on Off-Kilter, happy Mother’s Day to all the moms out there. Meanwhile, Mother’s Day isn’t just a time for appreciating the moms in our lives. It’s also a particularly somber holiday for many, considering that the U.S. has the highest maternal and infant mortality rates among comparable developed countries. As if that’s not bad enough, the survival rates for Black mothers and their babies are even worse. So I sat down with Jamila Taylor, a Senior Fellow and Director of the Women’s health and rights project at the Center for American Progress, marked Mother’s Day with a major new report that lays out a policy framework for tackling the structural racism driving racial disparities in maternal and infant health in America. Later in the show, a look at where things stand with Puerto Rico’s nutrition assistance crisis that’s left 1.4 million of the island’s residents hungry while Washington plays politics over a disaster package.

But first earlier this week the Trump administration announced a major new proposal to reduce the number of poor people in the U.S. But don’t get too excited… what they’re proposing wouldn’t actually boost anyone’s incomes. Rather what they’re proposing is the change the poverty measure used by the federal government to artificially reduce, I’m putting “reduce” in scare quotes, the poverty rate. So I brought in my friend Jared Bernstein, a senior fellow at the Center on Budget and Policy Priorities and former chief economist to then Vice President Biden to help unpack what Trump’s proposing and what it would mean. Jared, thanks so much for taking the time to join the show.

JARED BERNSTEIN: My pleasure.

VALLAS: So Jared, I feel like before we step into what this specific proposal would do and there’s a lott there it probably makes sense to actually move up a level or two and explain how we measure poverty in this country currently. It gets wonky but Jared there’s nobody who does it quite like you.

BERNSTEIN: The question is how do we measure poverty in America and the answer is we measure it pretty badly. Unfortunately the threshold by which we determine who is poor, that is the income threshold were devised many decades ago and were pretty quickly obsolete. So what we do, we look at your income before tax and we compare that income to the set of the thresholds which are adjusted for different family types. Obviously a family with say, two parents and two kids needs less income than a family with two parents and three kids. So they have all these different poverty thresholds and every year we collect a sample data on the income of households in America. We compare that income to the threshold and decide who is poor. The problem is it’s going to become important in that conversation is that the threshold themselves are not only highly unrepresentative of who is poor, they are considerably too poor so we underestimate poverty in America.

VALLAS: So using the current measure that we have what do we know about how many poor people we have officially and then I’d love you to actually paint a picture of some better measures so that we have a baseline before we head into what this administration’s proposing to do.

BERNSTEIN: So right now the poverty rate is somewhere around, a little below 13% as I recall and that’s going to be in a country of 300 million people that’s going to be somewhere north of 40 million poor people. Thankfully the census data has done really good work at the federal level using alternative measures of poverty that correct some of these problems of the unrepresentativeness of the official poverty threshold. These account for where people live, they account for medical cost, childcare cost, they account for changing places that people have to [INAUDIBLE]. And those poverty rates tend to be a couple of points higher than the official one. So that is fortunate that we have those but those aren’t the official ones and programs eligibility are benchmarked off of poverty, they come from the official measure.

VALLAS: And the other statistic I always love to throw in when we’re using official measures of poverty just because it does a better job of helping people understand what’s going on, you’ve got in this country right now about 4 in 10 American families are struggling to afford food and housing and health care and other kinds of basics. So just to give a little bit of a comparison point that helps to underscore exactly what you said Jared of what a poor job that official measure does of counting poor people in this country. It’s actually a lot to closer to 4 in 10 families in this country. So Jared what is Trump actually proposing to do with this number fudging thing that’s started to gain some attention in the news?

BERNSTEIN: So the proposal is to change the way these poverty thresholds are calculated every year in a way that will make them overtime even lower than they are now. And if the threshold is lower that means fewer people will be considered poor. Basically let’s just make it very concrete. Let’s say the poverty threshold is around $15,000 and your income is $14,000 so you’re going to be considered poor because $14,000 is less than $15,000. Let’s say we now reduce that poverty threshold to $13,000. Well now you’re $14,000 income makes you no longer poor. So how are they going to do this? How will they reduce these thresholds, which are already too low, how are they going to reduce them over time, they’re going to change the inflation adjustment. So every year the poverty threshold adjusted by the Consumer Price Index, now they’re going to adjust it by a different type of CPI, it’s a variation on that. It’s called the chained CPI, we can get into the details of the technical differences but the point is that the proposed adjustment grows more slowly than the traditional one and because the inflation adjustment grows less, the poverty thresholds will be lower. You’ve got that dynamic that I explained before.

Let me say it one other way because this is kind of tricky to wrap your head around. Let’s say you’re a poor family, your income is just below the poverty line, so the poverty line is $15,000 and your income is $14,900 so you’re just below the poverty line, you’re poor and you’re eligible for services that poor people get. Let’s say your income grows 2% and inflation also grows 2%, well you’re still poor. Your income grew 2% in nominal terms but the inflation threshold also goes up 2%. What if instead of going up 2% the inflation threshold goes up 1.5%? You’re no longer going to be counted as poor and that’s the kind of adjustment they’re doing.

By the way, I want to clarify something I said earlier. I said the poverty rate was slightly below 13%, actually it’s 12.3% the official poverty rate in 2017 the most recent one we have so it’s lower than that but it’s still about 40 million Americans or so.

VALLAS: So Jared just to sum up what you were describing, if we were to switch the way that the poverty thresholds change over in the way that this proposal says we do we would effectively be pushing the poverty thresholds further and further down over time even though it seems like a slight change in this moment. And what you’re starting to describe is that there are very real consequences to changing how we use these kinds of official government statistics and the formulas that get put into them because there’s a lot of stuff that’s pegged to those thresholds including eligibility for public assistance and I want to get into that for a second. But before we get into that wonkery I also feel like it’s really important to say out loud the broader context here of what we’re watching come from this Trump administration with this move, which is that here we’ve got a president trying to say that there’s an economic miracle taking place in the United States, that’s a direct quote from his state of the union as folks may recall and that’s very much the brand that he’s trying to sell given his campaign promises, given what he’s trying to say is coming from his tax law but there’s this really inconvenient truth which is that we’ve got close to half the country struggling to make ends meet on his watch. And so is it fair to say that this is an effort to redefine poverty away to make it seem like a smaller problem then it actually is.

BERNSTEIN: No question, the result of this proposal will be to make it look like there’s fewer poor people without doing anything to help the poor. That is, the way by which we measure poverty will and you were correct about this over time show fewer and fewer poor people relative to the current approach. So we’ll have fewer poor people, we’ll have lower poverty rates but we won’t have spent one dime to help poor people. All we’re doing is changing the measuring stick not the living standards of families who are struggling to make ends meet. And let’s be very concrete about this the poverty threshold for say a single mom with a couple of kids is about $20,000 a year. There may be some rural areas where you can barely get by on that amount, I actually don’t think there are. But there are certainly no cities you can do that in. So again the threshold are already inadequate to describe the hardship that’s out there. And you cited some other statistics about food insecurity that underscore that. But this would be a way to show that you actually lowered poverty without helping the poor.

VALLAS: And you would also be effectively I think a phrase I used the other day in describing this is it’s like mathematical gaslighting. You’re basically changing up the math to tell a whole bunch of people who can’t afford to food on the table or put a roof over their heads, oh don’t worry, we made you less poor.

BERNSTEIN: Right that’s precisely the right way to look and this and here’s the way I described it because I was also thinking about the tax cuts which of course bestow all kinds of economic largess on those at the very top of the scale. And if you look at the tax cuts which are a reality, that’s not a proposal as we all know that was passed and the benefits are already flowing to corporate coffers and to the wealthy. And then you look at that in tandem with this proposal it seems that the problem the Trump administration is trying to solve is rich people don’t have enough and poor people don’t have too much and I just don’t know too many right thinking people out there who would sign onto that.

VALLAS: Now the broader context off this is where you were starting to go and where I think we should go next which is what are the potential ripple effects that we would see from this. It wouldn’t just be able shrinking the number of people who are officially counted as poor. There are also real life consequences that would take a serious human toll if this policy were to take effect. It’s a backdoor way to slash a whole bunch of public assistance programs, isn’t that right?

BERNSTEIN: It is right and the key there is if all we were doing was tweaking the measurement to look like there’s been progress against poverty when there hasn’t that would be bad enough but it wouldn’t take the toll that this would actually take overtime because the poverty thresholds are how we often measure the eligibility for various programs that help low income people. So SNAP, used to be called food stamps, Medicaid, even the Affordable Care Act which goes pretty high up the pay scale, you can get premium assistance help pay your insurance on the open market if you had an income up to multiples of the poverty line, school lunches these programs are, housing programs, these are all keyed to the poverty line. So if you make fewer people look like they are poor at the same time you are going to make fewer people eligible for benefits.

VALLAS: And of course a lot of the programs that you just named listeners of this show will know very well are the kinds of programs that Trump has spent his entire presidency trying to slash through legislation, failing in a lot of regards to do that way so turning around, trying to do it through an administrative attack including most recently on SNAP that you were just describing so in effect it’s like his administration has found yet another backdoor way to cut programs that they haven’t successfully been able to cut through the front door.

BERNSTEIN: Yeah and that’s true and I guess to me maybe because it’s been happening over the last couple days but this one has particularly gotten under my skin and that’s a high bar in this administration because like you said earlier they’re always up to something in this space. But take the work requirements which the Trump administration are trying and successfully in fact through waivers to states imposing on people who receive nutritional support or health coverage through Medicaid and they’re basically saying if you don’t follow your work requirements you can use your eligibility to these programs. Well that is a kind of transparent thing. We can have a good argument about whether that is a good idea or a bad idea, my colleagues at the Center on Budget have shown that the work requirements are just a pure hassle factor to kick people off the rolls, most able bodied people are already trying to work. But this one, they’re trying to sell as a technical fix, it’s sort of like nothing to see here folks, just move along, all we’re doing is tweaking a price deflator in a way that’s going to generate a more accurate measure. It’s really very much a wolf in sheep’s clothing.

VALLAS: Let’s talk about part of what you just brought up there because some proponents, I’ll erect the straw man, here I go, some proponents of this policy are saying it will make our poverty measure more accurate. Now it’s hard for me to even say that out loud with a straight face but there we have our straw man. What do we know about the kind of a claim when it comes to what inflation looks like for low income people and their cost of living.

BERNSTEIN: Well that claim is evil on a couple of levels. It’s very misleading on the level that I mentioned a second ago, making it sound like an antiseptic adjustment when it has very stark consequences for our least advantaged folks. But it also is answering a question, the one we just ask that we don’t know the answer to. It is assuming that prices for low income people grow more slowly than is reflected in the consumer prince inflator. This chained CPI better represents prices faced by the poor. We don’t know if that’s the case and before we want to go and make a change like that we need to know more about that. There are a couple of research papers and I’ve just been digging through them over the last few days that show and this is a historical finding and probably wouldn’t surprising listeners who apply common sense, poor people often pay more for things that the rest of us can drive to outlets and pay lower prices, we can buy a house instead of renting and rental inflation has been going up a lot more quickly than overall inflation, we can find retail sources that are going to give us price benefits. Poor people can’t always do that so that’s unknown but here’s the thing. If you convinced me that you had a more accurate price adjustment for the poor than the one we currently use I still would not advocate applying it to the current threshold because the current threshold is really broken. SO if you’re telling me we can do a better job of adjusting a broken threshold that’s not what I want to do. What I want to do and I think we need to do if we actually want to figure out who is poor in this country is apply a much better measuring stick to more accurately figure out who is poor and then we can apply the best inflation adjustment to that measure. We’re using a poverty threshold that we devised in the early 1960s that by the person who actually came up with it, a very smart woman named Molly [INAUDIBLE] said in so many words I don’t expect this to last because it’s keyed off of the low income food budget that people were accessing in the late 1950s so that’s how out of date this measure is so I don’t want to focus on, I think it’s analytical incorrect to focus on a better adjustment to a broken threshold. And this isn’t a better adjustment.

VALLAS: And if people are hearing you describe the origins of the federal poverty measure and hearing the name Molly Orshansky and going where do I know that name from, well if you don’t spend a ton of time studying the history of how we measure poverty in this country it might be from a famous West Wing episode which of course was the first thing I thought of when I saw this proposal actually get announced and news reports started to break about it because do you remember Jared that West Wing episode where they were grappling with the fact that a more accurate poverty measure would cause it to look like poverty had gone up on the president’s watch and that wasn’t something they wanted to do and so there was active debate about instead keeping the poverty rate measured poorly which isn’t as bad as this proposal would go which would make it less accurate but in a way that didn’t grapple with the fact that there are a lot of people in this country who don’t have enough to get by.

BERNSTEIN: Let me just tell you that I’ve never watching one minute of the West Wing in part because I used to work in the White House and it just didn’t seem like a good way to relax. But that’s really interesting that they had a show on that and I really have to find that episode because that’s precisely what has bedeviled even administration that get everything we’re saying, and there have been administration like that I worked for them. They’re like yeah we get it but we don’t want to have poverty go up 12 to 14% on our watch simply because we’ve changed the metric. So what they’ve done and I really think the Census Bureau deserves a lot of praise for this is they developed a supplemental measure which is more accurate and does end up with higher rates.

VALLAS: I will confess I wish the conversation we were having is the one you are describing which is how do we measure hardship in a real way in this country that doesn’t just take the political easy route to look at what would look good in a press release but grapples with the actual cost of living. So I feel like I would be remiss in the last couple minutes that I have with you if I didn’t give you an opportunity to talk about the cost of living, there are a lot fo organizations out there the Economic Policy Institute and others who have done cost of living calculators and other analyses to really look at that question not just from the standpoint of who is officially poor under the guidelines.

BERNSTEIN: Yeah so it so happened just I have a piece in today’s Washington Post that gets into this in some detail. It starts with this observation that because the job market is so tight and wages have been going up and they’ve been going up for low income workers which is great, no question. But we can’t just look at wage trends if we want to ask this question about whether people are getting by. We also have to look at wage levels. And I point out that the wage level for the 20% worker a typical low wage workers in this country is about $12 an hour, that’s about $24,000 a year. A minute ago I said for a poor mom with a couple of kids that will get her family over the poverty line but will it enable them to meet their basic needs that’s the question you’re asking, that’s the question that a a bunch of calculators get at, EPI has one, MIT has one and I use some of these in my article and I can tell you that they are multiple, 2 and 3 times that of the poverty line. So I happen to be looking at Ohio and for a family with a couple of kids in Ohio the family budget line was about $56,000 which is more than twice that of the poverty line. It doesn’t mean that everybody below that is poor but that everybody below that is going to engage in some struggle to meet adequate child care, decent housing, to afford health coverage that’s reliable so I wouldn’t think of it in terms of necessarily poverty but I would think of it as a middle class family would recognize as meeting the basic standards of living, those are multiples of the poverty line.

VALLAS: I’ve been speaking with Jared Bernstein, he’s a senior fellow at the Center of Budget and Policy Priorities and also a former chief economist to then Vice President Joe Biden. Jared thanks so much for taking the time to demystify this wonky but super important topic.

BERNSTEIN: Thank you for having me on.

VALLAS: And I would be fully remiss if I didn’t advise our listeners to check out our nerdy syllabus page where we have a link to comment in the next 44 days which is what you’ve got to raise your voice and tell the administration what you think about this proposal and we’ll have some additional resources on the page as well to help you formulate a comment. Jared thanks so much for taking the time.

BERNSTEIN: My pleasure.

VALLAS: Don’t go away, more Off Kilter after the break, I’m Rebecca Vallas.

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You’re listening to Off Kilter, I’m Rebecca Vallas. “If the fact that the United States has the highest maternal and infant mortality rates among comparable developed countries is not bad enough, the survival rates for African American mothers and their infants are even more dismal African American women across the income spectrum and from all walks of life are dying from preventable pregnancy-related complications at three to four times the rate of non-Hispanic white women, while the death rate for black infants is twice that of infants born to non-Hispanic white mothers.” So opens a new report entitled “Eliminating Racial Disparities in Maternal and Infant Mortality” released on Mothers’ Day by the Center for American Progress, I’m thrilled to talk next with Jamila Taylor, a senior fellow and director of the women’s health and rights project at the Center for American Progress who’s the lead author on that report. Jamila thanks so much fo taking the time to join the show.

JAMILA TAYLOR: Thanks for having me.

VALLAS: So I mentioned a couple of incredibly stark statistics up top that start to paint a picture of tremendous racial disparities when it comes to this issue which really is a public health crisis. There are a lot more statistics that further paint that picture in your report, they’re woven through this report that you and others just came out with from the Center for American Progress. Help situate this public health crisis with what we know and what the role of racism is in these disparities.

TAYLOR: Absolutely so racism drives the high rates of maternal and infant mortality in this country. We know that African American women across education and income levels are disproportionately impacted by these issues, in fact African-American women with advanced degrees have higher infant mortality rates than non-Hispanic white women who never finished high school. And I think we should pause for a minute and really digest that point. The fact that racism is an underlining point here, this stat in and of itself lifts that up and shows how racism is really personified in the unequal treatment in health care access that Black women have in this country. 60% of maternal deaths are preventable, common conditions associated with maternal mortality such as coronary conditions and hemmorage rates at approximately 70%. Black women are 50% more likely than non-Hispanic white women to give birth preterm. On average African-American women receive lower quality health care than their non-Hispanic white peers and here we know that the disparity in care and quality of care starts as early as birth with African-American infants in neo-natal intensive care units receiving lower quality care than non-Hispanic white women’s and this continues throughout adulthood with three out of four black women giving birth at low quality hospitals. And these are also hospitals where the rest of poor maternal health outcomes is the highest. Lastly I’ll just noted that more than 1/3 of Black women undergo cesarian sections even with low risk pregnancies and this is 4% higher than the U.S. average and higher than any other racial or ethnic group.

So these are some of the major stats in the piece but they are really folded throughout that really bring us back to the point that racism is the underlying factor here and when we use the term racism and structural racism what we’re saying is that there are inequalities that manifest themselves in the lives of black women whether it’s through their access to health care, whether or not the hospital that is closest to them in their neighborhood is a low quality hospital. We know from the stats that I mentioned that low quality hospitals tend to be concentrated in majority Black neighborhoods so also that gets to the piece about the environment. Where do Black women tend to live and work their access is limited as well as the quality of care they receive and so all of this culminates in this perfect storm where we’re being poor maternal health outcomes, poor infant health outcomes that have translated into the fact that the US has one of the highest maternal mortality rates in the developed world and Black women are bearing the brunt of that.

VALLAS: Now a lot of people might be listening and hearing the phrase structural racism and thinking yeah I’ve heard that a lot. Help unpack that a little bit so we can understand it through a lens that one might apply to a public health crisis like this one and that’s very much the argument that’s at the center of this report is that we need to apply that lens to this particular public health crisis.

TAYLOR: Absolutely, so structural racism is defined as a system where public policies, institutional practices and cultural representations work to reinforce and perpetuate racial inequality. And so this is fueled by predominately white power structures that perpetuate power imbalances among people of color. This means that the policy solutions that we want to put forth the address this particular issue, maternal and infant mortality must be grounded in social justice frameworks that intentionally address those power imbalances.

VALLAS: So make that concrete here, people might be hearing racism is fueling these massive disparities in health outcomes but how does that actually play out when it comes to a Black woman seeking access to health care in this kind of a situation?

TAYLOR: It plays out into who gets what. We know that because Black women are experiencing racism and inequality in the health care system that could manifest itself in a myriad of ways. It could manifest itself in the fact that she may present in a hospital setting and her provider could have preconceived notions or biases based on the color of her skin or whether or not she is low income and then we know from what we’re seeing in terms of the research behind these disparities is that this does impact the care she receives, it impacts whether or not she’s listened to if she expresses pain or discomfort. It impacts the treatment that she receives, how that health care provider responds to her health needs and then even outside of the healthcare system research also shows that the racism that Black women experience throughout the life span, we are in the United States so unfortunately racism is a given for people of color we know that the cumulative of experiencing racism throughout the lifespan impacts women’s’ mental health. This also makes Black women more likely to have maternal complications like high blood pressure and corinary conditions. It really is a perfect mix of poor health outcomes based on the experiences we have throughout the lifespan which is on one end fascinating but also very sad because these racist foundations in this country hav been around since the beginning and we are in a better place in this country, people are in a better position in terms of our neighborhoods and safety and having access to income and education but we know even those are not protective factors for Americans. So to really address this issue we have to look at racism. No matter how educated or how much money we have we can’t wipe off or erase this skin color and that is impacting our health and our health outcomes.

VALLAS: How does this concept and structural racism as a lens for understanding a public health crisis intersect with the concept of social determinants of health?

TAYLOR: So the social determinants of health they are important, they including things like income level, education, and socioeconomic status but again talk about those factors in the context of maternal and infant mortality we know that they are not protective. When we look at socioeconomic determents of health as we apply them to other communities they do actually protect folks from having poorer health outcomes but in this case they do not. So this is also why we have to go back to racism, social determinants of health technically are there to effect the life of people in their given environment, where they live, where they work, or where they play but again racism is part and parcel of being Black in this country and so we need to center the racism piece because we know that those social determinants are not protective factors for us.

VALLAS: So the argument in your report that flows from the case you make for applying structural racism to public health crisis for these massive racial disparities in maternal health and maternal mortality and infant mortality you make the case for then applying a framework that is consistent with a social justice way of thinking about the problem that’s called reproductive justice. You make arguments for applying reproductive justice to this problem as opposed to a purely medicalized framework. Now reproductive justice might be a phrase that listeners are going yeah I’ve heard that before but I’m not entirely sure what it means, how is it different from reproductive rights for example? What is the 101 to reproductive justice and how its is dissimilar to the reproductive rights framework some might be familiar with.

TAYLOR: Before I talk through what it means I want to give a nod to the Black women that coined the term reproductive justice in the 90s. Women like Loretta Ross and Toni Bond Leonard and other folks like that who have paved the way for me to be here today talking to you about this issue. So reproductive justice recognizes that a women’s ability to determine her reproductive destiny including her access to health care, affordable housing, economic opportunity and other factors. And so again when we think about the policy solutions that will help address maternal and infant mortality using the reproductive justice framework to contextualize this issue. These policy solutions must prioritize communities of color in their realities to full address racial disparities in maternal and infant mortality.

VALLAS: So it’s really about thinking not just about the problem as a medical one —

TAYLOR: Right, or in isolation.

VALLAS: But the power imbalance centering that piece of it in how we solve the problem.

TAYLOR: Right, the power imbalance is also I think the intersectionality in not only my, I’m a black woman, not only in my ability to be healthy but also how my housing situation may impact that or my economic opportunities or how I experience or internalize racism on a day to day basis. Those things are going to impact my daily life and my ability to live a healthy productive life.

VALLAS: So your report also in addition to provide this structural racism based analysis of the problem also begins to layout an incredibly thorough framework for what the policy solutions and changes are that we need to see happen to close these gaps and start to address this public health crisis. The policy solutions fall into a range of different categories some of which have to do with the health care system itself and some of which are much farther reaching and break into whole other sectors of our social policy. Where would you like to start in terms of laying out those solutions?

TAYLOR: Well first I want to encourage folks that are listening to read the report. It is very comprehensive and robust in terms of the policy solutions that we lay out here. It is one of the most comprehensive frameworks that I have seen to date to address these issues. So we have divided the policy solutions into five broad areas. The first is improving access to critical services. This includes health care services and support services for women and families. And so under this umbrella we really focus on strengthening existing health programs like the Affordable Care Act, Medicaid and the Children’s Health Insurance Plan but also recognizing that particularly women and infants of color still lack access to care that keeps them healthy. So in addition to strengthening these programs we also need to protect the health of these communities by speaking out against harmful restrictions, having policymakers augment screening and treatment for women at risk of preterm birth, ensuring that all women have access to high quality maternity care, no matter where they live and then also supporting families to navigate health setting and have access to midwives and doulas and really a diverse care network that will help them have healthier outcomes. The second area is focused on improving the quality of care provided to pregnant women, so here we acknowledge the fact that in this country we spend so much money on health care but we know that we still have this maternal and infant mortality crisis. So policymakers must improve quality of care by addressing racism in the health care system through training and recruiting diverse, compassionate and respectful workforce, developing standardized evidence based guidelines in care assessment of mothers and infants and adopting new models of care by family experiences by linking payment to quality. We also focus on addressing maternal and infant mental health. Again this is an important aspect in the conversation around maternal and infant mortality because we know that too often particularly moms in the post pardon period lack the support that they need to be healthy and then to help them maintain their daily routine with the care of a new baby. So here ensuring access to mental health care providers, helping to address some of the barriers to care that include high out of pocket costs and the lack of available providers, then also ensuring screenings in moms and infants for mental health issues. The fourth area is enhancing supports for families before and after birth. So here again focusing on making sure that women and families even those with economic insecurity have access to wraparound services and other supports, making it easy for them to apply to those programs. We really advocate and lift up current community programs that are a one stop place for families to apply to the services that they need and also supporting education of families in terms of health literacy. And the last area we focus on is improving data collection and oversight. Over the past year a lot of the conversation around addressing this issue has focused on collecting better data. So there has been legislation that actually was passed in 2018 and signed by the President focused on giving states’ grants for material mortality review committees which we think is an important first step. But we need need these committees to include a diverse set of stakeholders at the table to assess these deaths and then we also advocate for a similar body, a fetal and infant mortality review committee and also ensuring that these bodies have the financial support and training to promote equity in these review committees. And then also they need to be considering the social determinants of health as they are assessing these deaths and births.

VALLAS: The recommendation section of your report does not pull any punches, it actually gets very concrete about some of the particular proposals that we’ve been seeing coming from this administration and from some leadership in this congress that would actually sent us even farther back if we were to see these changes in effect and some of those policies are actually happening as we speak. Things like erosion of Medicaid in the states, ongoing attacks on nutrition assistance which we know would disproportionately impact African-American families in this country, some are actually not just proposals but are in progress as we speak and risk to set up even farther back when it comes to these gaps. What is the right path forward when ti comes to public assistance programs that often carry some level of racialization in how they get villanized particularly by those who seek to cut them but programs that we know are in some ways most important for the folks who are bearing the brunt of these types of disparities.

TAYLOR: Absolutely it’s not just enough to increase funding for them, I will say that. A big issue that we saw as we were doing research for this report is the fact that the process to apply for these program is complex for families and so this is why we advocate for the services and supports to be colocated to ensure that it’s easier for families to apply for those programs. I think you made an important point about the racialization of these programs and even the rhetoric around who is accessing these programs and the shame in the language that some of our leaders tend to us in terms of folks that access these programs. There should never be any shame in accessing services that you need. So I think we need to continue to shed a spotlight on that and continue to push back on that. I think that’s an important piece of the conversation and really just helping to support families to meet their basic needs in terms of the enrollment process. So I think the gist of it is making it easier to get families comprehensive health and social services and funding multiple services in the one location is the big focus of this section.

VALLAS: Recognizing our listeners are nerds and so I actually many of them are going to go and read this report and find it on the nerdy syllabus page.

TAYLOR: I hope so.

VALLAS: Dig in and what you’ve given them is just a teaser but in the last minute or so that we have there’s a really important point that I also don’t want to get buried in this incredibly far reaching report that takes us further than the population of African-American women and their families that we’ve been talking about today, actually makes the case that all of these types of policy solutions would help all mothers and children and that’s because of a framework called targeted universalism. For folks, we’ve introduced a lot of terms that probably are buzzwords that do warrant defining what is targeted universalism and why does it make sense here as we’re thinking about a public health crisis that impacts more than just African American women but hits them the hardest.

TAYLOR: So targeted universalism is an equity framework. We use a lot of frameworks in this paper and part of that is to help the reader to understand how we are contextualizing these issues and how racism is a factor and how important equity is in the context of these policy solutiosn. Targeted universalism is a framework that employs targeted strategies to achieve a universal goal. And so what the framework does is its allows policy solutions to meet the needs of all populations but they do have an intentional focus on those most in need in this case it’s African-American women and families.

VALLAS: I’ve been speaking with Jamila Taylor senior fellow and director of the Women’s Health and Rights Project, Center for American Progress and the author of the report we’ve been describing along with others you can find it on our nerdy syllabus page and I know you can’t wait to take a read now. Happy Mothers’ Day I hope you’ll be celebrating in ways not just thinking about horrible racial disparities this Mothers’ Day.

TAYLOR: Thank you so much for having me and happy Mothers’ Day to all the mothers that are listening. This issue is important to us at CAP and for mothers day I will be thinking about these women because we have to.

VALLAS: Don’t go away, more Off Kilter after the break, I’m Rebecca Vallas.

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You’re listening to Off Kilter, I’m Rebecca Vallas. With a disaster package stalled in Congress since March Puerto Rico has been suffering from a massive nutrition crisis that’s left 1.4 Puerto Rico residents with less money to put food on the table. So to close out this week’s episode I talk with Javier Balmaceda, senior policy analyst on Puerto Rico at the Center on Budget and Policy Priorities for a look at how we got here and an update on where things stand. Javier thanks so much for taking the time to join the show.

JAVIER BALMACEDA: Thank you Rebecca for having me.

VALLAS: Your work at the Center on Budget you focus on Puerto Rico and there has been a tremendous amount to focus on in the past several months but as Puerto Rico has contributed to struggle to recover from the devastation from Hurricanes Irma and Maria as well as larger structural and financial problems that the island has been facing for some time one of the crisis level problems has been around Puerto Rico’s nutrition assistance program which is not called SNAP, it is not called Supplemental Nutrition Assistance Program, it’s called NAP, before we get into what the crisis is help us understand a little bit of how does nutrition assistance in Puerto Rico work and that will set us up to get back to where we are now.

BALMACEDA: That’s exactly right Rebecca, the program functions different in Puerto Rico than it does in the rest of the US and two other territories which are the US Virgin Islands and Guam which have full access to SNAP. In Puerto Rico it’s a little different, what Puerto Rico gets is something called a block grant which is a capped amount of money every year. And Puerto Rico uses that to finance the nutritional assistance program which is NAP and that’s Puerto Rico’s version of food stamps. And the having a block grant to finance NAP complicates things because Puerto Rico cannot expand or contract the program depending on need. So that means Puerto Rico gets a fixed amount of money every year and whether that is enough or not to cover all the nutritional needs of low income residents in Puerto Rico, it doesn’t matter. If it’s enough it’s enough, but if it isn’t, it isn’t. And in this case we have a very poor jurisdiction, 44% of the population of Puerto Rico lives under the poverty line and the current amount of money that Puerto Rico gets to finance NAP is simply not enough to cover all the nutritional needs of the poorest people on the island and obviously with the impact of the hurricane that became all the more apparent as needs increased.

VALLAS: Take us back to the hurricane, hurricanes happen, you’re describing a picture where the nutrition assistance program already isn’t enough to provide enough benefits to enough of the low income families on the island but after the hurricanes congress did take some action to provide some additional NAP funding to the island what happened right after the hurricanes?

BALMACEDA: After the hurricanes hit Puerto Rico congress did take action and provided additional money that would supplement the annual amount that Puerto Rico to finance NAP. And one thing to point out is as opposed to SNAP, which expands automatically after natural disasters, because Puerto Rico gets a fixed amount through the block grants Puerto Rico needs to go and ask for more money if a natural disaster hits. So that’s different from the state effected by Katrina which automatically got more money, same thing after the financial recession in 2008 because SNAP expands to meet rising need. In Puerto Rico that didn’t happen so Puerto Rico had to ask for an additional sum of money from congress, they did approve it and it was five months later, March of 2018 congress began providing that additional money. And that additional money allowed Puerto Rico to do two things. It allowed to increase benefits because again the block grant isn’t enough so Puerto Rico provides benefits that are on average lower than the territories that have access to SNAP. In addition to the increased benefits Puerto Rico was able to take new people into he program which it wasn’t able to afford before. That additional pool of money lasted until roughly March of this year and after that Puerto Rico ran out of that money and that meant that Puerto Rico went back too the usual levels of the NAP block grant. And this has been talked about and reported widely as the So-called NAP cliff. And when the NAP cliff hit in March you had a dramatic decrease in benefits again for a lot of families still strugging, shrugging to put food on eh table, you say wide and sweeping cuts, roughly an average of 35 to 40% a dramatic cut that has impacted the island severely.

VALLAS: There’s legislation on the table that would address this problem but it’s not something we’re seeing be top of anyone’s list in congress, what is the fix that we could see and what are the politics here, why are we seeing congress not take action?

BALMACEDA: As far back as last year lawmakers took action to introduce a disaster package that including additional NAP aid to avoid the cliff, the house introduced a version and the senate introduced a different version. The version in the house was a lot more generous and included many more aids not just for Puerto Rico but also for Pacific island territories that need health care funding. The senate version was less generous and that led to an impasse between both chambers and the package has essentially stalled ever since. It’s been taken up again now after recess, both chambers aren negotiating every day but the package has yet to pass the cliff has already hit Puerto Rico and we have other territories struggling to meet their health care needs as well, that’s where we are right now, we just don’t know everything seems to be up in the air. The reports that tell that lawmakers are negotiating we just don’t know what’s happening in the meantime people are really suffering.

VALLAS: Javier you mentioned the other territories that stand to benefit from this disaster package and have significant needs with respect to health care what’s going on in the territories and what’s their stake in the disaster package?

BALMACEDA: So in addition to the Puerto Rico you have three territories, the Northern Marinana islands, Guam, and American Samoa and these three territories desperately need health care funding especially because they’ve been hit by very powerful cyclones and typhoons that have devastated their health care infrastructure. The house version of the package includes important health care funding that’s not included in the senate version so we often talk about Puerto Rico not having everything it needs but these territories also need this aid for health care funding and that’s included in one of the versions of the bill and not in the other. And that’s also another thing that needs to be addressed.

VALLAS: There’s a long term need when it comes to Puerto Rico and nutrition assistance. You started to apply it with some of what you were describing before about the limitation with the block grant that provides insufficient resources for nutrition assistance for the Island what’s the conversation you with we were having when it comes to Puerto Rico’s nutrition assistance needs and the way that it’s not the way the program currently operates?

BALMACEDA: I would say that the way that the program currently operates, the amount of funding it receives, the main problem that it’s simply not enough to cover all the low income residents in Puerto Rico and obviously the hurricanes exposed and exacerbated that need but it signals to a much longer term systemic fault that goes way beyond the short term, it talks about a funding system that seems to be broken and that’s not covering all the nutritional needs of the people in Puerto Rico. I think that much was clear when Puerto Rico received the additional funding from congress because the two things that Puerto Rico need to do immediately was not just elevating benefits to the same level as SNAP which is the way it operates everywhere else in the United States but also Puerto Rico was able to bring in new participants and that goes to show that were Puerto Rico to have the additional money it needs there’s a lot more need to be covered on the island.

VALLAS: But of course the immediate need before we have that longer term conversation is for congress and for the president to join in providing the governor with the requested funds so that people who are trying to find where their next meal is coming from can meet their basic food needs.

BALMACEDA: That’s exactly right.

VALLAS: What is it that people can do in this exact moment if they’re wondering where they can learn more and how they can get involved in trying to elevate this issue.

BALMACEDA: To toot my own horn a little bit but they can go to our website, we’ve put out some good materials on these issues, I think the press has done a good job reporting on these issues, Puerto Rico seems to make headlines left and right these days and talking about the issues and being aware that Puerto Rico is not just suffering from short term problems caused by the hurricane but there are more sustainable faults at play here, people often aren’t aware of and only become explicit when two giant hurricanes hit Puerto Rico. We shouldn’t wait for natural disasters to happen to address these longer term needs because they’ve always been there, they’ve been there for many decades now and we should start working on whatever policy decision to avoid this happening in the future and have resilient infrastructure in place.

VALLAS: And they can find some of your work and the Center’s resources on our nerdy syllabus page as well. I’ve been speaking with Javier Balmaceda, he’s a senior policy analyst who focuses on Puerto Rico for the Center on Budget and Policy Priorities. Javier thank you so much for your work on this and for taking the time to join the show.

BALMACEDA: Thank you so much for having me and for elevating these issues as well.

VALLAS: And that does it for this week’s episode of Off Kilter, powered by the Center for American Progress Action Fund. I’m your host, Rebecca Vallas, the show is produced each week by Will Urquhart. Find us on Facebook and Twitter @offkiltershow and you can find us on the airwaves on the Progressive Voices Network and the WeAct Radio Network or anytime as a podcast on iTunes. See you next week.