Why Cash Transfers Save Lives in Tanzania but Not Texas

In Tanzania, $20 per month can save lives. In Texas, hundreds of dollars barely move health metrics. Same intervention, vastly different outcomes. What explains this global paradox of cash assistance?

The Cash Transfer Revolution That Wasn't

Cash transfers have become the darling of social policy. Over the past decade, dozens of American cities launched guaranteed income pilots. The pandemic saw governments worldwide dramatically expand cash programs. As AI reshapes work, universal basic income has entered mainstream political discourse.

Yet the results tell a puzzling story. While cash transfers have saved countless lives across low- and middle-income countries, they've produced only modest health gains in the United States. The same policy tool that transforms communities in Kenya struggles to make a dent in Kentucky.

Researchers studying cash transfer programs across 37 countries have identified a consistent pattern: cash transforms health only when four specific conditions align. Most US pilots have missed the mark on all four.

The Four Pillars of Effective Cash Assistance

Size matters—dramatically. In many developing countries, $20 monthly represents a major share of household income. For families living in extreme scarcity, this modest sum can expand food budgets, enable childhood vaccinations, or help mothers reach hospitals for safe delivery. These aren't marginal improvements—they're life-saving interventions.

US guaranteed income pilots typically provide a few hundred dollars monthly for relatively short periods. While this eases financial stress, it rarely matches the steep costs of housing, childcare, and healthcare that define American poverty. The support provides breathing room but doesn't fundamentally alter daily constraints.

Target the right barriers. In the countries studied, leading causes of death—HIV, tuberculosis, malaria, malnutrition—are tightly linked to poverty. Small amounts of money can immediately overcome life-threatening obstacles by providing transportation to clinics, access to better nutrition, or skilled birth attendants.

America's dominant health problems are chronic diseases shaped by neighborhood environments, structural healthcare inequities, and years of accumulated risk. These conditions resist short-term financial interventions. Cash can reduce stress and improve stability, but it cannot undo the deep roots of diabetes, heart disease, or mental health conditions.

Scale creates spillover effects. Successful programs reach large population segments. When millions receive support, benefits spread beyond individual households, helping explain why such programs have reduced mortality across entire countries. US pilots typically reach only hundreds or thousands of families—too limited to change broader conditions shaping health outcomes.

Integration amplifies impact. In many countries, payments link with health visits and essential services. Brazil's Bolsa Família operates alongside an extensive primary care system and has prevented hundreds of thousands of deaths. US cash transfer studies typically operate in isolation from other programs that could translate money into health gains.

SNAP: America's Accidental Success Story

One American program comes remarkably close to global success stories: SNAP, the federal food assistance program. Its payments are large enough to meaningfully reduce poverty. The program targets food security, directly tied to health and survival. It reaches more than 40 million people. And it connects, albeit imperfectly, with other public systems including Medicaid and school meals.

It's no coincidence that SNAP is the only US income support program convincingly linked to improved survival. Expansions during the Great Recession and pandemic demonstrated that larger benefits and smoother access make the program far more effective.

Yet recent policy moves in the opposite direction. The Trump administration has justified SNAP cuts by citing fraud and abuse. While fraud occurs in any large federal program, government estimates show it represents a small fraction of spending. The vast majority of tens of billions in SNAP funding benefits Americans as intended.

Beyond SNAP: Building on What Works

Other programs offer instructive examples. The Earned Income Tax Credit delivers sizable cash benefits as lump sums that low- and moderate-income workers use for necessities. Built into tax filing, it avoids eligibility churn and can be readily expanded. Past expansions have linked to improved child health.

WIC pairs food support with nutrition counseling and care referrals for pregnant women, infants, and young children. By targeting a crucial life period and integrating with healthcare, WIC has improved birth outcomes and infant health.

Smaller programs can also succeed when designed right. Rx Kids, launched in Flint, Michigan, in 2024, follows the global playbook: meaningful transfer size, near-universal city reach, benefits targeting pregnancy and infancy, and links to the health system. Early evaluations suggest substantial birth outcome improvements. Michigan's decision to invest hundreds of millions expanding Rx Kids statewide shows a plausible US path to scale.

The Returns on Investment

These programs require public investment, but returns can be extraordinary. For young children, SNAP delivers roughly $60 in benefits for every dollar spent. The question isn't whether cash gets misused—research consistently shows minimal work disincentives and no increase in substance use. The question is whether we structure programs where cash does the most good.