Table 1 Next steps for research on unconditional cash transfers for preterm infants and their caregivers

Area of Study and Key Unanswered Question

Comments

Dose: What is the optimal “dose”, or monetary amount of a UCT, to produce meaningful outcomes for preterm neonates?

More research is needed on the optimal UCT “dose” for preterm neonates. Researchers must consider that the “dose” needed may vary with the outcome under study (i.e. the “dose” needed to improve the frequency of parental visitation during a NICU stay may be smaller than the “dose” needed to impact infant mortality).

Frequency: What is the optimal UCT frequency to produce meaningful outcomes for preterm neonates?

More research is needed on the optimal UCT frequency for preterm neonates. Researchers must consider that UCTs can be delivered as large, infrequent sums (like the yearly delivery of the EITC), or in smaller, more frequent sums (like the delivery of monthly payments with the 2021 CTC expansion).

Timing: What is the optimal UCT timing to produce meaningful outcomes for preterm neonates?

Ideally, UCTs be timed to begin pre-conception or during pregnancy as an intervention to prevent preterm birth. However, in the absence of these policies in the prenatal period, researchers should consider UCTs for preterm neonates. More data are needed on the timing of cash interventions after birth - including whether they are more effective during the NICU stay, after the NICU stay, or during both time points.

Health Outcomes: Do UCTs improve neonatal health outcomes?

Key infant health outcomes may include infant mortality, morbidity, and neurodevelopment (both short- and long-term). Beyond describing impacts on health outcomes in the aggregate, more data are needed on health impacts stratified by race and ethnicity as a measure of health equity, as well as qualitative data on the lived experiences of families.

Mechanisms of Action: What are the mechanisms through which UCTs may impact neonatal health outcomes?

Mediators along the causal pathways may include impacts on household income and income stability, caregiver stress and cognitive burden, caregiver health and well-being, the quantity and quality of caregiver time investments in the care of their infant, and caregiver access to resources to optimize the health and well-being of their infants.

Healthcare Utilization: Do UCTs impact healthcare utilization among preterm neonates?

This may include measures of the impact of UCTs on primary care and neonatal follow-up program attendance, engagement in physical, occupational, and speech therapy, enrollment in Early Intervention, and acute care utilization.

Cost-Effectiveness: Are UCTs delivered to families of preterm neonates cost-effective?

More data are needed on the extent to which early periodic investments may reduce costs in the long term. Reductions in costs for preterm neonates may be related to costs of the initial NICU stay, costs of subsequent acute care and readmissions, costs associated with prematurity- related morbidity including specialized medical care and special education services, and lost household and labor market productivity (both for the parent and the child later in adulthood) associated with the child’s morbidities.

Unintended Negative Consequences: What are the potential unintended consequences related to the delivery of UCTs to preterm neonates?

Some families may lose government benefits due to the increased income from UCTs. This is often called the “cliff effect,” in which families may experience a small increase in income that results in them exceeding income limits for several government benefits, even by a small amount. While many pilots can pursue waivers to exempt the income from being taxable or from impacting government benefits, some government benefits are highly likely to be affected (like Supplemental Security Income).

It is also possible that UCT policies may be implemented to replace (as opposed to complement) current social safety net programs, which may have unintended consequences and could result in a net welfare loss to families should the UCT received have a lower value than the social safety net programs it replaced.

Families may also have reductions in other earned income through deferred work. Measurements of impacts on earned income will require a nuanced approach and careful selection and interpretation of outcome measures. UCTs may allow caregivers to spend more time with their infant before returning to work, which could result in lower earned income and may not reflect the positive impact of the cash transfer.