Food Insecurity and Health Care Expenditures in the United States, 2011-2013

State-Level and County-Level Estimates of Health Care Costs Associated with Food Insecurity

INTRODUCTION

Food insecurity, or uncertain access to food because of limited financial resources, is associated with higher health care expenditures. However, both food insecurity prevalence and health care spending vary widely in the United States. To inform public policy, we estimated state-level and county-level health care expenditures associated with food insecurity.

METHODS

We used linked 2011-2013 National Health Interview Survey/Medical Expenditure Panel Survey data (NHIS/MEPS) data to estimate average health care costs associated with food insecurity, Map the Meal Gap data to estimate state-level and county-level food insecurity prevalence (current though 2016), and Dartmouth Atlas of Health Care data to account for local variation in health care prices and intensity of use. We used targeted maximum likelihood estimation to estimate health care costs associated with food insecurity, separately for adults and children, adjusting for sociodemographic characteristics.

RESULTS

Among NHIS/MEPS participants, 10,054 adults and 3,871 children met inclusion criteria. Model estimates indicated that food insecure adults had annual health care expenditures that were $1,834 (95% confidence interval [CI], $1,073-$2,595, P < .001) higher than food secure adults. For children, estimates were $80 higher, but this finding was not significant (95% CI, -$171 to $329, P = .53). The median annual health care cost associated with food insecurity was $687,041,000 (25th percentile, $239,675,000; 75th percentile, $1,140,291,000). The median annual county-level health care cost associated with food insecurity was $4,433,000 (25th percentile, $1,774,000; 75th percentile, $11,267,000). Cost variability was related primarily to food insecurity prevalence.

CONCLUSIONS

Health care expenditures associated with food insecurity vary substantially across states and counties. Food insecurity policies may be important mechanisms to contain health care expenditures.

Implementation of a Rooftop Farm Integrated With a Teaching Kitchen and Preventive Food Pantry in a Hospital Setting

Safety-net hospitals serving populations with disproportionately high levels of poverty, food insecurity, and chronic disease can utilize innovative strategies to improve the health and environment of their communities. Boston Medical Center in Boston, Massachusetts, constructed an on-site rooftop farm to provide fresh produce for the hospital's preventive food pantry, teaching kitchen, cafeterias, and inpatient meal services. This novel model can be replicated by other organizations aiming to alleviate food insecurity, encourage healthy eating, and promote environmental sustainability.

Food Security and 10-Year Cardiovascular Disease Risk Among U.S. Adults

INTRODUCTION

Cardiovascular disease is a leading cause of mortality in the U.S. Although the risk of cardiovascular disease can be mitigated substantially by following a healthy lifestyle, adhering to a healthy diet and other healthy behaviors are limited by reduced food security. This study aims to determine the association between food security and cardiovascular disease risk.

METHODS

Three samples from the 2007-2014 National Health and Nutrition Examination Survey were examined: (1) 7,340 non-fasting adults (aged 40-79 years); (2) 13,518 non-fasting adults (aged 20-64 years); and (3) 6,494 fasting adults (aged 20-64 years). Food security was assessed using the U.S. Household Food Security Survey Module, with households categorized as having full, marginal, low, or very low food security. Regressions were conducted in 2018 to test the associations between food security status and odds of ≥20% 10-year cardiovascular disease risk among middle-aged to older adults (OR, 95% CI) and cardiovascular disease risk factors among all adults (β, 95% CI).

RESULTS

Compared with adults with full food security, those with very low food security had higher odds of ≥20% 10-year cardiovascular disease risk (OR=2.36, 95% CI=1.25, 4.46), whereas those with marginal food security had higher systolic blood pressure (β=0.94 mmHg, 95% CI=0.09, 1.80). Compared with adults with full food security, adults with different levels of food security had higher BMIs (marginal: 0.76, 95% CI=0.26, 1.26; low: 0.97, 95% CI=0.34, 1.60; and very low: 1.03, 95% CI=0.44, 1.63) and higher odds of current smoking (marginal: OR=1.43, 95% CI=1.17, 1.75; low: OR=1.47, 95% CI=1.22, 1.77; and very low: OR=1.95, 95% CI=1.60, 2.37).

CONCLUSIONS

Adults with food insecurity have elevated cardiovascular disease risk factors and excess predicted 10-year cardiovascular disease risk. Substantially improving food security may be an important public health intervention to reduce future cardiovascular disease in the U.S.

Medically Tailored Meals as a Prescription for Treatment of Food-Insecure Type 2 Diabetics

Type 2 diabetes mellitus is an immense burden to the health of our population and to our current health care system, and the weight of this burden is only projected to multiply in coming years. A nutritious diet is an indispensable aspect of diabetes treatment, and the lack of access to food engenders poor disease-state control, which correlates with increased health care utilization. Interventions aimed at improving access to food through medically tailored meals (MTMs) have demonstrated effectiveness in improving the health of food-insecure type 2 diabetic patients and reducing health care costs. Further studies are necessary to increase the external validity of existing positive research on medically tailored meals in food-insecure diabetic patients and to provide evidence to support potential policy changes under which the costs of medically tailored meals for diabetics might be covered by insurers.

Trends in Food Insecurity and SNAP Participation among Immigrant Families U.S.-Born Young Children

Immigrant families are known to be at higher risk of food insecurity compared to non-immigrant families. Documented immigrants in the U.S. <5 years are ineligible for the Supplemental Nutrition Assistance Program (SNAP). Immigration enforcement, anti-immigrant rhetoric, and policies negatively targeting immigrants have increased in recent years. Anecdotal reports suggest immigrant families forgo assistance, even if eligible, related to fear of deportation or future ineligibility for citizenship. In the period of January 2007–June 2018, 37,570 caregivers of young children (ages 0–4) were interviewed in emergency rooms and primary care clinics in Boston, Baltimore, Philadelphia, Minneapolis, and Little Rock. Food insecurity was measured using the U.S. Department of Agriculture’s Food Security Survey Module. Overall, 21.4% of mothers were immigrants, including 3.8% in the U.S. <5 years (“<5 years”) and 17.64% ≥ 5 years (“5+ years”). SNAP participation among <5 years families increased in the period of 2007–2017 to 43% and declined in the first half of 2018 to 34.8%. For 5+ years families, SNAP participation increased to 44.7% in 2017 and decreased to 42.7% in 2018. SNAP decreases occurred concurrently with rising child food insecurity. Employment increased 2016–2018 among U.S.-born families and was stable among immigrant families. After steady increases in the prior 10 years, SNAP participation decreased in all immigrant families in 2018, but most markedly in more recent immigrants, while employment rates were unchanged.

Trends in Food Insecurity and SNAP Participation among Immigrant Families U.S.-Born Young Children

Immigrant families are known to be at higher risk of food insecurity compared to non-immigrant families. Documented immigrants in the U.S. <5 years are ineligible for the Supplemental Nutrition Assistance Program (SNAP). Immigration enforcement, anti-immigrant rhetoric, and policies negatively targeting immigrants have increased in recent years. Anecdotal reports suggest immigrant families forgo assistance, even if eligible, related to fear of deportation or future ineligibility for citizenship. In the period of January 2007-June 2018, 37,570 caregivers of young children (ages 0-4) were interviewed in emergency rooms and primary care clinics in Boston, Baltimore, Philadelphia, Minneapolis, and Little Rock. Food insecurity was measured using the U.S. Department of Agriculture's Food Security Survey Module. Overall, 21.4% of mothers were immigrants, including 3.8% in the U.S. <5 years ("<5 years") and 17.64% ≥ 5 years ("5+ years"). SNAP participation among <5 years families increased in the period of 2007-2017 to 43% and declined in the first half of 2018 to 34.8%. For 5+ years families, SNAP participation increased to 44.7% in 2017 and decreased to 42.7% in 2018. SNAP decreases occurred concurrently with rising child food insecurity. Employment increased 2016-2018 among U.S.-born families and was stable among immigrant families. After steady increases in the prior 10 years, SNAP participation decreased in all immigrant families in 2018, but most markedly in more recent immigrants, while employment rates were unchanged.

Aligning Programs and Policies to Support Food Security and Public Health Goals in the United States

Food insecurity affects 1 in 8 US households and has clear implications for population health disparities. We present a person-centered, multilevel framework for understanding how individuals living in food-insecure households cope with inadequate access to food themselves and within their households, communities, and broader food system. Many of these coping strategies can have an adverse impact on health, particularly when the coping strategies are sustained over time; others may be salutary for health. There exist multiple opportunities for aligning programs and policies so that they simultaneously support food security and improved diet quality in the interest of supporting improved health outcomes. Improved access to these programs and policies may reduce the need to rely on individual- and household-level strategies that may have negative implications for health across the life course.

Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries

Delivering food to nutritionally vulnerable patients is important for addressing these patients' social determinants of health. However, it is not known whether food delivery programs can reduce the use of costly health services and decrease medical spending among these patients. We sought to determine whether home delivery of either medically tailored meals or nontailored food reduces the use of selected health care services and medical spending in a sample of adults dually eligible for Medicare and Medicaid. Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program. Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending. These findings suggest the potential for meal delivery programs to reduce the use of costly health care and decrease spending for vulnerable patients.

Evaluation of Food Insecurity in Adults and Children With Cystic Fibrosis: Community Case Study

Advances in the care and treatment of cystic fibrosis (CF) have led to improved mortality rates; therefore, considerably more individuals with CF are living into adulthood. With an increased number of CF patients advancing into adulthood, there is the need for more research that surrounds the aging adult CF patient. It is important to conduct research and collect results on the aging CF population to help better prepare the CF patient, who is dealing with the heavy treatment and financial burden of their disease, build autonomy and increase their quality of life. Of note, research has found that social, behavioral, and physical factors influence the ability of those with CF to follow dietary recommendations. A primary treatment goal in CF is a high calorie, high protein, and high fat diet. A socio-economic factor that has not been adequately investigated with regards to dietary compliance of individuals with CF is food insecurity. The aim of this community case study was to document the experiences and estimate the prevalence of food insecurity among CF patients residing in Idaho. The correlation between food insecurity and health outcomes (lung function and body mass index) was also examined. Participants included adult patients and parents of pediatric patients with CF. Food insecurity rates among CF patients of all ages were found to be significantly higher than that seen in the overall community; however, no specific correlation between food insecurity and body mass index (BMI) or lung function emerged. This case study highlights the need for continued research around food access issues in this patient population. The data resulting from this study shows the value of CF advocacy organizations promoting efforts to build resources and provide education around food insecurity issues.

Complexities of Addressing Food Insecurity in an Urban Population

There is an association between food insecurity, poor health outcomes, and increased health care spending. The Temple Food Insecurity Program was initiated to screen patients for food insecurity as part of the post Temple University Hospital discharge process. The community is economically challenged and food insecurity is a significant problem. Food insecure patients were identified and referred to community-based resources, with a 30-day follow-up call. Screening was successful in 3655 patients, 27% (n = 987) of whom reported food insecurity. Of these patients, 66% (n = 647) were already receiving benefits through the Supplemental Nutrition Assistance Program (SNAP), but were still food insecure. All patients with food insecurity were referred to one of 2 resources for help. Despite significant need, less than a quarter of patients connected with these resources. Qualitative data revealed that some patients did not remember the information provided to them, were overwhelmed with poor health or other social determinants of health, had competing priorities, did not perceive the need for food assistance; and experienced system barriers. Health literacy also was an issue. Health care systems addressing food insecurity should consider the high prevalence of food insecurity in impoverished regions, the reality that SNAP benefits may not alleviate food insecurity for many patients, and the need for individualized, custom care plans that address barriers and reflect patient priorities and capabilities. Engaging patients differently may be aided by additional communication from community food resources directly to patients who provide permission for this added service.

Incremental Health Care Costs Associated With Food Insecurity and Chronic Conditions Among Older Adults

INTRODUCTION

The prevalence of food insecurity and chronic health conditions among older adults is a public health concern. However, little is known about associated health care costs. We estimated the incremental health care costs of food insecurity and selected chronic health conditions among older adults, defined as adults aged 50 or older.

METHODS

We analyzed 4 years of data (2011-2014) from the National Health Interview Survey and 3 years of data (2013-2015) from the Medical Expenditure Panel Survey; we used 2-part models to estimate the incremental health care costs associated with food insecurity and 9 chronic conditions (hypertension, coronary heart disease, stroke, emphysema, asthma, cancer, chronic bronchitis, arthritis, and diabetes) among older adults.

RESULTS

Approximately 14% of older adult respondents (n = 2,150) reported being food insecure. The 3 most common chronic conditions were the same for both food-insecure and food-secure older adults: hypertension, arthritis, and diabetes. The adjusted annual incremental health care costs resulting from food insecurity among older adults were higher in the presence of hypertension, stroke, and arthritis (P ≤ .05) and in the presence of diabetes (P ≤ .10). These findings were also true for the incremental health care costs resulting from food insecurity in the absence of these specific chronic conditions.

CONCLUSION

Our findings show that food insecurity interacts with chronic conditions. We observed higher health care costs in the presence of this interaction for those who were food insecure and had poor health than for those who were food secure.

Perspectives from the Society for Pediatric Research: interventions targeting social needs in pediatric clinical care

The social determinants of health (SDoH) are defined by the World Health Organization as the "conditions in which people are born, grow, live, work, and age." Within pediatrics, studies have highlighted links between these underlying social, economic, and environmental conditions, and a range of health outcomes related to both acute and chronic disease. Additionally, within the adult literature, multiple studies have shown significant links between social problems experienced during childhood and "adult diseases" such as diabetes mellitus and hypertension. A variety of potential mechanisms for such links have been explored including differential access to care, exposure to carcinogens and pathogens, health-affecting behaviors, and physiologic responses to allostatic load (i.e., toxic stress). This robust literature supports the importance of the SDoH and the development and evaluation of social needs interventions. These interventions are also driven by evolving economic realities, most importantly, the shift from fee-for-service to value-based payment models. This article reviews existing evidence regarding pediatric-focused clinical interventions that address the SDoH, those that target basic needs such as food insecurity, housing insecurity, and diminished access to care. The paper summarizes common challenges encountered in the evaluation of such interventions. Finally, the paper concludes by introducing key opportunities for future inquiry.

Lessons Learned from Implementation of the Food Insecurity Screening and Referral Program at Kaiser Permanente Colorado

Traditionally, health care systems have addressed gaps in patients' diet quality with programs that provide dietary counseling and education, without addressing food security. However, health care systems increasingly recognize the need to address food security to effectively support population health and the prevention and management of diet-sensitive chronic illnesses. Numerous health care systems have implemented screening programs to identify food insecurity in their patients and to refer them to community food resources to support food security. This article describes barriers encountered and lessons learned from implementation and expansion of the Kaiser Permanente Colorado's clinical food insecurity screening and referral program, which operates in collaboration with a statewide organization (Hunger Free Colorado) to manage clinic-to-community referrals. The immediate goals of clinical screening interventions described in this article are to identify households experiencing food insecurity, to connect them to sustainable (federal) and emergency (community-based) food resources, to alleviate food insecurity, and to improve dietary quality. Additional goals are to improve health outcomes, to decrease health care utilization, to improve patient satisfaction, and to better engage patients in their care.