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Measuring the health impact of Universal Basic Income as an upstream intervention: Holistic trial design that captures stress reduction is essential

Abstract

In the context of the UK Government's 'prevention agenda', Laura Webber and colleagues have called for a 'health in all policies' approach. Universal Basic Income (UBI) is a system of cash transfers to citizens and recent research suggests it may have a significant impact on health, including via an underexplored role in reduced stress. However, debate has been influenced by a recent Finnish trial of a policy with similarities to UBI. This was reported as a failure due to a policy objective of reducing unemployment, despite demonstrating significant benefits to wellbeing. In this article, we advance this debate by exploring the current evidence and proposing a practical way forward. We propose a need to refocus evidence collection in UBI trials on improved health-via reduced stress-to provide policymakers with the means of producing an accurate cost-benefit analysis. We argue that previous trials have either not reflected likely UBI policy or have not measured a sufficient range of impacts to enable accurate analysis of its cost-benefit. We contend that interdisciplinary work is needed in order to establish trials that observe key factors driving the social health gradient. Finally, we argue that statistical modelling is needed to extrapolate short-term findings to long-term population-level outcomes. One implication is that substantial allocation of resource is required from Government and/or major research funders. On the other hand, this presents an opportunity to pioneer an interdisciplinary approach resulting in joined-up evidence and policy for UBI and 'upstream' interventions.
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Measuring the health impact of Universal Basic Income as an upstream intervention:
Holistic trial design that captures stress reduction is essential
Elliott Johnson,
1
Dr Matthew Johnson
2
and Dr Laura Webber
3
This is an Author’s Original Manuscript (AOM) of an article published by Bristol University
Press in Evidence & Policy, available online:
https://doi.org/10.1332/174426420X15821054636126
Abstract
In the context of the UK Government’s ‘prevention agenda’, Laura Webber and
colleagues have called for a ‘health in all policies’ approach. Universal Basic Income
(UBI) is a system of cash transfers to citizens and recent research suggests it may have
a significant impact on health, including via an underexplored role in reduced stress.
However, debate has been influenced by a recent Finnish trial of a policy with
similarities to UBI. This was reported as a failure due to a policy objective of reducing
unemployment, despite demonstrating significant benefits to wellbeing. In this article,
we advance this debate by exploring the current evidence and proposing a practical way
forward. We propose a need to refocus evidence collection in UBI trials on improved
health via reduced stress to provide policymakers with the means of producing an
accurate cost-benefit analysis. We argue that previous trials have either not reflected
likely UBI policy or have not measured a sufficient range of impacts to enable accurate
analysis of its cost-benefit. We contend that interdisciplinary work is needed in order
to establish trials that observe key factors driving the social health gradient. Finally, we
argue that statistical modelling is needed to extrapolate short-term findings to long-term
population-level outcomes. One implication is that substantial allocation of resource is
required from Government and/or major research funders. On the other hand, this
presents an opportunity to pioneer an interdisciplinary approach resulting in joined-up
evidence and policy for UBI and ‘upstream’ interventions.
Keywords: Universal Basic Income; stress; public health; social health gradient
Key messages
1. Existing Universal Basic Income trial designs have not enabled accurate assessment
of the policy
2. Interdisciplinarity is needed in trials to observe key factors driving the social health
gradient
3. Statistical modelling is essential to produce population-level evidence for policy
development
4. Financial resource must be directed to establishing more thorough and evidence-
based trials
1
Elliott Aidan Johnson, MA, Disability Research Consultant. ORCID ID: 0000-0002-0937-6894.
ejohnsonresearch@gmail.com
2
Matthew Thomas Johnson, PhD, Senior Lecturer in Politics, Lancaster University. Politics, Philosophy and
Religion, County South, Lancaster University, Lancaster, United Kingdom, LA1 4YL. ORCID ID: 0000-0002-
9987-7050. m.johnson@lancs.ac.uk
3
Chief Operating Officer and Co-founder, HealthLumen; Honorary Assistant Professor, London School of
Hygiene and Tropical Medicine. 35 Ballards Lane, London, N1 1XW. Laura.Webber@healthlumen.com.
ORCID ID: 0000-0002-8976-1919
2
Introduction
The UK Government has recently developed a Green Paper on health advancing a ‘prevention
agenda’ (Department of Health and Social Care 2019). With concern about the NHS being
understood as the ‘National Hospital Service’ (see Department of Health and Social Care and
Hancock 2018; Department of Health and Social Care 2018), there is an emerging commitment
to promote action conducive to avoidance of ill-health. In that context, Laura Webber and
colleagues (2018) have called for a ‘health in all policies’ approach grounded in ‘upstream
interventions’. We (Johnson and Johnson 2019; Johnson, Geyer and Degerman 2019) recently
cited the prospective value of Universal Basic Income (UBI) to this end, arguing that its
prospective effect in mitigating social sources of stress provides a qualitative shift in
justification of the policy toward those in, as well as out of, work. Such an intervention offers
the possibility of dealing with the crisis in stress-related ill-health that imposes significant costs
on the NHS and wider society. In part because of this research (see Standing 2019, 17-19), the
UK Labour Party committed to trialling UBI in such cities as Liverpool and Sheffield in its
2019 Manifesto (Labour Party 2019, 60; Press Association 2019). In the wake of the
Conservative Party’s success in the 2019 General Election, Hull City Council has sought
permission to conduct a trial of UBI (Halliday 2019).
However, in 2018, a trial of a system with similarities to UBI in Finland was not extended
beyond two years, despite calls from the nation’s social security agency to do so (Henley 2018).
Reporting of this focused on its ‘failure’ to increase employment, despite improved wellbeing
for participants (Henley and agencies 2019, Pohjanpalo 2019). This perceived failure resulted
from narrow policy objectives within the centre-right Government that focused solely on
reducing the unemployment rate (Valero 2019). Payments were given only to unemployed
people and at a rate that was only around €50 above the previous benefit. Little change to the
unemployment rate in a system of payments to all citizens would actually have the potential to
counter criticism of UBI as likely reducing incentive to work (Gibson, Hearty and Craig 2018,
100). But the effect of evaluating UBI against a requirement to increase employment has been
to cloud interest in it as a policy that addresses challenges to wellbeing. Our contention is that
wellbeing in particular UBI’s potential effect on health via stress is crucial to the social and
economic value of UBI as a policy. If policymakers are to be equipped with the means of
calculating the cost-benefit of UBI through its impact on all in society, not solely those who
are unemployed, trials that take proper account of population-level wellbeing are essential.
While the BMJ has called for a trial on health grounds (Painter 2016), and while trials of UBI
have indicated self-reported reductions in stress (Kangas, et al. 2019, 30), existing research has
failed to measure psychobiological stress in ways that establish UBI’s value as an upstream
health intervention. This is because all measures of stress are subject to biases in interpretation,
especially given the influence of factors like physical activity on cortisol levels (Gerber, et al.
2012). In the case of self-reported psychological stress, there are also challenges in subjective
reporting (Brant, et al. 2010; Epel, et al. 2018, 4). All have value in predicting future health
outcomes (Epel, et al. 2018, 38-39), but physiological stress, in particular, has been studied in
ways that enable predictive modelling for particular conditions and overall mortality (Kumari,
et al. 2011). In this analysis, we highlight deficits in trials and present recommendations for
future research.
UBI and health
UBI is a system of universal cash transfers to (adult) citizens that is typically presented as an
alternative reduced to need-based welfare systems. It differs starkly from Universal Credit,
which is currently being introduced in the UK to replace a number of means-tested benefits
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and which is tapered down as recipients enter work and earn above a set threshold (Government
Digital Service 2014). UBI is paid to all regardless of means or needs, though there is debate
over whether it should be conditional on good citizenly behaviour (participation in voting,
avoidance of crime, etc.). Historically, it has been justified by those on the left and right
variously as a means of promoting citizens’ rights (Pettit 2008) within a state (see discussion
in Ferry 1995), increasing efficiency in welfare systems (Gordon 2014) and promoting growth
(Sheahan 2003). Because UBI has been seen as an economic instrument, the notion of
deploying UBI specifically for reasons of public health, and grounding those reasons in the
medical literature, marks a key development within the field.
Trials of programmes that resemble UBI have often noted an effect on health (Gibson, Hearty
and Craig 2018; Haagh and Rohregger 2019). The Canadian case of Mincome, in Manitoba,
which provided an unconditional payment to lower income households (an income guarantee
similar to negative income taxation), established a series of impacts, such as adult mental health
and hospital admissions (Forget 2011). The US case of Gary Indiana, in which low income
families received a minimum income guarantee, demonstrated an impact on birth weight
(Kehrer and Wohlin 1979). These schemes are in no substantive way comparable to the forms
of UBI proposed for the UK because they are targeted at low income groups in which poverty
is a significant driver of ill-health. Indeed, initial socioeconomic status (SES) was shown to be
the key explanatory factor of obesity in the US case of Tribal Casino Cash Transfers, in which
Indigenous Americans receive twice annual taxable cash payments (Akee, et al. 2013). Such
studies suggest potential impact on health from those forms of UBI that increase income among
those with low income, but they have neither been designed in such a way as to map health
impact via reduction in social sources of stress nor to evaluate impact on whole populations.
Indeed, in general, few have either advanced health as a primary or key justification for UBI
or designed evaluations of trials in such a way as to measure effect reliably and holistically.
This inconsistency may be because proponents assume an effect, because they believe health
to be an ancillary concern or because the means by which to understand and assess that effect
are complex and demand methodological precision. As Gibson, Heart and Craig (2018, 11)
note,
A number of studies reported modest to strong positive effects on a range of health
outcomes, including low birthweight, adult and child mental health, service use, and
diet. Improved parenting quality and reduced financial strain were among the suggested
mechanisms underlying some of these improvements. These effects were less
consistent than those for labour market outcomes and educational participation,
possibly because the outcome measures or the samples included in the analyses
differed.
The possibility of an assumption of an effect is apparent in Richardson, et al.’s (2018, 4) model
examining the potential impact of income-based policies on health inequalities. This model
assumes a causal, linear correlation between income and mortality, in which an increase in
income will cause a decrease in mortality. Again, this assumption needs clarification.
UBI as a ‘health in all policies’ upstream intervention
UBI offers the capacity to deal with disincentives to healthy behaviour inherent in needs- and
means-based welfare systems (see Johnson and Spring 2018). People no longer face costs for
being active and making health-promoting decisions, such as avoiding opioid painkillers that
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are often seen as indicators of incapacity by fitness for work benefits assessments (Johnson,
Geyer and Degerman 2019).
However, as Johnson and Johnson’s (2018) review indicates, UBI’s larger impact may lie in
its prospective contribution to dealing with Britain’s crisis of stress. This crisis was responsible
for 44% of all work related ill health cases and 57% of all working days lost due to ill health
in 2017/18 (Health and Safety Executive 2018, 2), up from 37% and 45% in 2015/16 (Health
and Safety Executive 2016). Meanwhile, in 2010/11, more than a quarter (around 15 million
people) of the population of England had at least one long-term, stress-related chronic health
conditions such as heart disease, stroke, cancer, type 2 diabetes, arthritis and depression
(Department of Health 2012).
Stress is an evolutionary adaptation to enable humans to respond to short-term threats to
homeostasis. Perception of threat triggers a cascade of biological changes that prime the body
to respond to physical and existential harm, leading to ‘increased cardiovascular tone,
respiratory rate, and intermediate metabolism, along with inhibition of general vegetative
functions such as feeding, digestion, growth, reproduction’ (Smith and Vale 2006, 383; see
also, Henderson and Baum 2004).
While this serves us well in dealing with mortal threats during times of war and natural disaster,
we find that there are socio-economic circumstances that prime us for stress unnecessarily.
Research suggests that hierarchical organisational models, in particular, create forms of what
republican political theorists have termed domination: the capacity for individuals to make
arbitrary decisions that affect others without reference to those individuals’ interests.
This concept of domination refers to the possibility of harm being inflicted, rather than the
harm itself. In this regard, it refers to those sources of unpredictability that stem from the
actions of other human beings. The mere possibility of individuals being subject to arbitrary
decisions leaves them in a long-term condition of preparedness for threat that is to say, long-
term stressed by virtue of social unpredictability. Such an account is compatible with those that
focus solely on resource scarcity insofar as domination is the threat of the removal of means of
subsistence (i.e. through termination of employment). People’s exposure to domination
increases as their resource-base decreases, meaning that those at the bottom of hierarchies are
not just less wealthy than those above them, they are significantly more threatened by the
arbitrary decisions made by their superiors. Poverty is a cause of ill-health, but it is not the only
cause.
Domination does not refer to natural environmental unpredictability or freak accidents in
which, without malice aforethought, an individual inflicts harm on another. While UBI might
help us to deal with social sources of resolving the consequences of non-human or accidental
actions by granting individuals resources by which to repair damage to themselves or their
property, the primary source of unpredictability we suggest it mitigates is one in which, by
virtue of power imbalances, individuals are subject to social arbitrariness.
Johnson and Johnson’s (2018) review of the endocrinological and immunological literature
suggests that such a condition both decreases normal immune function and increases
autoimmunity, contributing to the physical ill-health concomitant to the mental health crisis.
This is borne out in the Whitehall II Study of Civil Servants, which demonstrates that as
individuals occupy lower positions in the hierarchy, they experience increased stress-related
ill-health, irrespective of their objective, absolute poverty. Further complicating Richardson et
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al.’s (2018) assumptions, Tang, et al (2016). showed that the gradient was compounded by
individuals’ perceived position in their perceived hierarchy.
While the impact of UBI on health in work is Johnson and Johnson’s (2018) novel contribution,
its relationship with welfare reform is also apparent. At present, the UK’s needs- and means-
based system renders individuals subject to decisions that are imposed upon them, apparently
arbitrarily, by those above them in the welfare bureaucracy. The reasons for those decisions
are seldom justified with regard to the interests of recipients and their consequences in terms
of health are profound, as the United Nation’s Special Rapporteur’s report on poverty illustrates
(Alston 2018).
In this social context, Johnson and Johnson argue that, if sufficiently generous to satisfy basic
needs, UBI gives people the ability to resist (i.e. by feeling protected from demeaning demands)
or leave (i.e. by resigning) conditions of domination, thus freeing them from stress. We argue
that trials now need to be designed to measure stress as both a psychological and, importantly,
biological phenomenon.
Discussion: Dealing with methodological deficits
The Whitehall II study provides a methodological blueprint for this purpose. The model
emphasises the need to analyse hormonal (particularly cortisol) patterns as well as ambulatory
blood pressure and heart rate to create a complete overview of physiological stress levels
(Marmot and Steptoe 2008). Present studies of UBI do not follow that model.
In the first instance, some trials, such as that in Finland, focus on self-reported psychological
stress. The literature demonstrates that the relationship between this and biological stress is not
necessarily straightforward (Epel, et al. 2018, 169). For example, individuals may either not
perceive their biological stress response accurately or self-report it differently for a range of
social reasons (Simpson, et al. 2008). This is indicated by studies that find no significant
association between biological stress and mood (Chida and Steptoe 2009). However, self-
reported measures should not be discarded, and play a role in establishing impact on areas such
as mental health and quality of life (Lombardo, et al. 2018). Rather, a cluster of measures, both
psychological (phenomenological) and biological (biomarkers), should be employed. We do
not suggest that health outcomes have not been measured. Rather, we simply argue that the
studies in which data has been gathered are not representative of the prospective UBI
programmes we would encounter in the UK and that they have failed reliably to measure all of
the pathways to health impact. Each measure furthers our understanding of the drivers and
markers of stress-related ill-health and provides greater potential for predictive modelling of
outcomes.
In the second instance, even those trials that do measure biological markers do so inaccurately.
This is apparent in Johannes Haushofer and Jeremy Shapiro’s (2016) evaluation of a trial of
unconditional cash transfers to low-income household units in Kenya. Their research appears
to demonstrate that, while there was a substantial impact of the transfers on subjective
psychological measures of wellbeing, there was no overall average reduction in cortisol levels
in the single measures taken before and after intervention. However, cortisol levels were
significantly lower when transfers were made to the wife rather than husband, when a lump-
sum rather than monthly payment was given and when it was large rather than small (Haushofer
and Shapiro 2018).
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While this may seem to challenge the justification for including biological measures of stress
in trials of UBI, there are two significant drivers for these results.
First, interventions at an overall, average level failed to challenge the underlying structural
reasons for stress within the communities. Payments to women that were intended to challenge
control of wealth by men may have been balanced out by its entrenchment within the group in
which transfers were made to men. Indeed, the control of wealth by one head of a household
runs counter to the principles of Universal Basic Income, in which self-determination and
financial security is guaranteed by payment to each and every citizen.
Second, as Haushofer and Shapiro acknowledge, cortisol levels vary substantially across the
day, rising sharply in the morning (the cortisol awakening response) and declining across the
day, as well as being affected by ‘food and drink, alcohol and nicotine, medications, and
strenuous physical exercise’ (Haushofer and Shapiro 2018, 11). While the authors obtained a
‘clean’ average through OLS regression to control for the influence of the above factors, this
ignored several key factors.
Unfortunately, overall levels of cortisol are a poor predictor of disease risk. Rather, it is patterns
across the day (and between days) that are an indicator of both future likelihood of ill-health
and hierarchically-driven stress. Cortisol awakening response (cortisol level on waking
followed by a rise that reaches a peak after 30 minutes) was correlated in Whitehall II both
with subjective stress levels and lower socioeconomic position (and, interestingly, gender)
which correlated with poorer health outcomes in general (Marmot and Steptoe 2008). A more
recent study has suggested that a ‘flatter slope’ of decline in cortisol across the day, rather than
heightened cortisol awakening response, is associated specifically with cardiovascular
mortality (Kumari, et al. 2011). Biological measures should not, though, be limited solely to
cortisol. Others employed by Whitehall II such as ambulatory blood pressure and markers of
chronic inflammation, like C-reactive protein, fibrinogen and interleukin 6 (IL-6) (Marmot and
Steptoe 2008) are also strong candidates for inclusion in pilots.
UBI’s core value in this context lies in promoting autonomy for each citizen and by challenging
hierarchies associated with the health gradient in whatever form they are constituted
(households, organisations, classes). This prospective benefit applies even to those relatively
removed from absolute poverty. Haushofer and Shapiro’s interventions targeted only a random
selection of ‘poor’ households, with ‘spillover’ effects on some neighbouring households.
Rather than promoting a flattening of hierarchy and individual autonomy, the intervention may
simply have reshaped particular relationships and entrenched relative poverty among those not
selected. Ultimately, the study measured only effects on those raised out of absolute poverty
(and those at the sharp end of this dynamic who were not selected for payment), rather than
others in hierarchies associated with poorer health outcomes, but not in absolute poverty.
Haushofer and Shapiro’s study is a step forward and a serious attempt to demonstrate the
influence that something approximating UBI might have on biological markers of stress. The
differences between group designs, notably the impact of gender, point to areas for follow up.
However, a different approach is required if we are to build upon the evidence of previous
studies and develop a trial aimed specifically at measuring public health impact. First and
foremost, any trial of UBI must be concerned with payments to individuals. Second, we must
follow Whitehall II and recent studies that have built on its findings and measure biological
stress more effectively. This includes through measurement of diurnal patterns of cortisol, as
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well as other indicators such as ambulatory blood pressure, heart rate and markers of chronic
inflammation. This more holistic and contextualised approach should be supported by
psychological, self-reported measures.
After more than thirty years, Whitehall II’s data continues to reveal relationships between stress
and health that suggest parameters for trials of UBI. Given that a UK Parliament last five years,
any trial must be conducted within a period not longer than two-to-three years so as to enable
introduction and evaluation of the pilot. In that regard, it is not feasible to measure health
outcomes themselves. Accordingly, while Kumari et al.’s study helpfully demonstrated the
relationship between flatter slopes in decline of cortisol across the day and increased risk of
cardiovascular deaths, the fact that it depended upon a six year follow-up means that trials of
UBI must instead focus on measuring the physiological processes that lead to the outcomes
(Kumari, et al. 2011). Put simply, a Government simply could not plan a trial outside a single
Parliament, since it would be possible that, even if successful, it would be dispensed with by a
successor for ideological, rather than, practical reasons.
In this political context, Webber and colleagues make a compelling case for public health
modelling and its power in leveraging policy change (Webber, et al. 2014). Statistical
modelling is an essential means by which to fill the evidence gap by simulating the medium-
and long-term impact of interventions if scaled up to a population level. At present, the design
of trials is depriving modelling of accurate data by which to scale the impacts of interventions.
Modelling can perform sensitivity analysis, account for poor quality data based on qualitative
assumption and provide evidence for, and inform the development of, a larger trial. However,
because the trials developed thus far have not been designed with impact on health in mind, let
alone to have that impact studied effectively, even the data that does exist may prove
insufficient to enable scaling. It is only by designing trials with health in mind and then
measuring impact on health accurately that modelling can provide us with the population level
data by which to establish benefit to society as a whole and to produce the evidential basis for
legislation. A Government committed to that policy would have every incentive to invest in
means of measuring impact as reliably and comprehensively as possible. The measures we
have outlined above take us toward a blueprint for such efforts.
Given that Hassard, et al. (2014) and Kalia (2002) both highlight the enormous impact of stress
on economic activity and outcomes, such measures would enable accurate assessment of
economic benefit of improved national health through introduction of UBI. This is an approach
that is consistent with the UK Government’s prevention agenda (Department of Health and
Social Care 2019).
Conclusion
Webber and colleagues highlight the opportunity of political realignment and the need for fiscal
prudence to reshape our policies to make a transformative, cumulative impact on health. If
societies are to achieve this, UBI ought to be considered seriously as a means of reducing social
inequalities, improving health, reducing the burden on the NHS and improving productivity.
Currently, debate has been informed by partial evidence of the social and economic benefit
against what would be a very large spending commitment. The trial of guaranteed payments to
unemployed people in Finland had the effect of clouding the policy debate about UBI. UBI is
not only different in its structure but also has very likely population-level benefits not
measured, or at least valued, in the Finnish context. Other trials have had broader objectives
but provided payments in a manner that might have embedded particular forms of social
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hierarchy and stress that UBI generally seeks to reduce or eliminate. Where systems closer to
UBI have been trialled, they have failed to measure effectively the likely mechanisms of impact
on population-level health and wellbeing.
Labour’s commitment to UBI at the 2019 election and interest in the policy at city- level
indicates that adoption of large-scale pilots is increasingly possible. However, reporting of
previous attempts and public scepticism about its feasibility mean that it is more important than
ever that trials be designed appropriately. If not, potentially transformative interventions that
meet Webber and colleagues’ criteria may be overlooked in favour of less effective
alternatives.
To achieve appropriate designs, collaborative work must take place between policymakers,
social, political and economic theorists, epidemiologists, biomedical scientists and
psychologists to ensure observation of all key factors associated with the social health gradient.
To support policy development, statistical modelling must be accounted for in this design to
extrapolate short- to medium-term data to long-term population-level outcomes across social
strata.
This will require substantial investment of resource from Government and/or major research
funders and would therefore face its own challenges. However, a comprehensive trial design is
the only way that an accurate cost-benefit analysis of a UBI policy can be facilitated prior to
national introduction. Indeed, such approaches should be considered for other ‘upstream’
interventions, given that UK Government spending on ‘preventive’ care in 2017 accounted for
just 5% of its total health expenditure.
Without evidence of substantial economic benefit that is possible with a comprehensive trial
and statistical modelling, it is unlikely that such significant interventions will be deemed viable,
by government or the public. Such a project could provide a platform to pioneer this
interdisciplinary approach resulting in the kind of joined-up evidence and policy that is so often
sought but found just out of reach in practice.
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... UBI has been advocated as desirable on a range of philosophical, health and economic grounds (see e.g. Johnson, Johnson, and Webber 2020;Martinelli 2017;Standing 2017). However, evidence on its broad public appeal is more mixed. ...
... For example, our respondents felt that a UBI scheme would be effective in reducing stress and anxiety. Reduced stress and anxiety have indeed been observed in multiple UBI-related trials and natural experiments, and these effects form a major part of the academic argument for the policy (Johnson, Johnson, and Webber 2020). ...
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The 2020 global COVID-19 pandemic has led to a marked increase in positive discussion of Universal Basic Income (UBI) in political and media circles. However, we do not know whether there has been a corresponding increase in support for the policy in the public at large, or why. Here, we present two studies carried out in April and May 2020 in UK and US samples. In study 1 (n=802), we find that people express much stronger support for a UBI policy for the times of the pandemic and its aftermath than for normal times. This is largely explained by the increased importance they attach to a system that is simple and efficient to administer, and that reduces stress and anxiety in society. In study 2 (n=400), we pit UBI against an equally-generous but targeted social transfer system. We find that, for pandemic times, support shifts towards UBI. This is partially explained by a number of perceived advantages, such as simplicity of administration and suitability for a changing world. Our results illustrate how a changing social and economic situation can bring about marked shifts in policy preferences, through changes in citizen's perceptions of what is currently important.
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Background Unconditional basic income is seen as a potential solution to decreasing job security and predicted automation of many routine jobs. The importance of upstream health determinants suggests that basic income could improve health and reduce health inequalities. Since the effects of a universal, permanent basic income would differ from those of a trial, extrapolation of impacts from existing evidence is difficult. However, studies of interventions that unconditionally provide substantial, regular payments to individuals or families can provide insights into the potential effects. We conducted a scoping review to identify and synthesise evidence that could inform the planning stage of potential basic income pilots in Scotland. Methods We searched eight bibliographic and eight specialist databases for articles published in English from database inception until April, 2017 (initial searches), and November, 2017 (later iteration). We included randomised controlled trials, quasi-experiments, qualitative studies, and controlled before–after studies reporting any outcome of unconditional payments for low-income people or the general population. Studies conducted in low-income countries were excluded. Initial searches indicated that there were important studies of other interventions, so relevant search terms were incorporated in further iterative searches. Results were screened by one reviewer and a second reviewer checked a 10% sample. Data were charted and thematically analysed, following recognised scoping review approaches. Findings From 1591 papers identified, we included 28 studies of ten interventions implemented in a range of contexts that used various evaluation methods. The interventions were heterogeneous, but some were universal and permanent, and all provided substantial, regular payments unconditionally. Studies measured effects on employment, health, education, crime, and other social outcomes. Evidence on health impacts was mixed, with some studies finding strong positive impacts on outcomes such as birthweight and mental health, whereas others reported no effect. There was some evidence that effects were stronger in more at-risk groups. Most studies reported little impact on labour market participation. Interpretation Fears of a large decrease in labour market participation due to basic income seem to be unfounded, but inference was often hampered by small samples or multiple intervention arms. Further small-scale pilots would be of limited usefulness. Funding What Works Scotland (ESRC ES/M003922/1, SPHSU15, and Scottish Government).