Supplemental Nutrition Assistance Program size and timing and hypertension-related emergency department claims among Medicaid enrollees

Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension

BACKGROUND

Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear.

OBJECTIVE

To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals.

DESIGN

Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data.

PARTICIPANTS

Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60.

MAIN MEASURES

The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern.

KEY RESULTS

On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (β = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (β = 0.44, S.E. = 0.041).

CONCLUSIONS

Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.

The impact of financial incentives and restrictions on cyclical food expenditures among low-income households receiving nutrition assistance: a randomized controlled trial

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) is the largest anti-hunger program in the United States. Two proposed interventions to encourage healthier food expenditures among SNAP participants have generated significant debate: financial incentives for fruits and vegetables, and restrictions on foods high in added sugar. To date, however, no study has assessed the impact of these interventions on the benefit cycle, a pattern of rapid depletion of SNAP benefits that has been linked to worsening nutrition and health outcomes over the benefit month.

METHODS

Low-income households not currently enrolled in SNAP (n = 249) received benefits every 4 weeks for 12 weeks on a study-specific benefit card. Households were randomized to one of four study arms: 1) incentive (30% incentive for fruits and vegetables purchased with study benefits), 2) restriction (not allowed to buy sugar-sweetened beverages, sweet baked goods, or candy using study benefits), 3) incentive plus restriction, or 4) control (no incentive or restriction). Weekly household food expenditures were evaluated using generalized estimating equations.

RESULTS

Compared to the control group, financial incentives increased fruit and vegetable purchases, but only in the first 2 weeks after benefit disbursement. Restrictions decreased expenditures on foods high in added sugar throughout the benefit month, but the magnitude of the impact decreased as the month progressed. Notably, restrictions mitigated cyclical expenditures.

CONCLUSIONS

Policies to improve nutrition outcomes among SNAP participants should consider including targeted interventions in the second half of the month to address the benefit cycle and attendant nutrition outcomes.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT02643576 . Retrospectively registered December 22, 2014.

Strengthening the Public Health Impacts of the Supplemental Nutrition Assistance Program Through Policy

The US Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) is the cornerstone of the US nutrition safety net. Each month, SNAP provides assistance to 40 million low-income Americans-nearly half of them children. A number of changes could strengthen the public health impacts of SNAP. This review first presents a framework describing the mechanisms through which SNAP policy can influence public health, particularly by affecting the food security, the diet quality, and, subsequently, the health of SNAP participants. We then discusspolicy opportunities with the greatest potential to strengthen the public health impacts of SNAP, organized into three areas: (a) food production and distribution, (b) benefit allocation, and (c) eligibility and enrollment. For each section, we describe current policy and limitations of the status quo, suggest evidence-based opportunities for policy change to improve public health, and identify important areas for future research.

New SNAP Eligibility in California Associated With Improved Food Security and Health

INTRODUCTION

In California, Supplemental Security Income beneficiaries were ineligible to receive Supplemental Nutrition Assistance Program (SNAP) benefits until a June 2019 policy change. The objective of this study was to determine whether SNAP eligibility was associated with changes in food insecurity and health among older adults and adults with disabilities.

METHODS

We administered a survey to SSI recipients (N = 213) before (May-August 2019) and after (September 2019-January 2020) the policy change. We examined changes in food insecurity (primary outcome), health status, stress, medication adherence, and dietary intake from baseline to follow-up. Multivariable analyses adjusted for age, sex/gender, race/ethnicity, and education.

RESULTS

Of 213 participants at baseline, 56.8% were male, 43.7% were Black/African American, 88.7% had an annual income of less than $15,000, and 89.7% were currently housed. Of 157 participants at follow-up, 114 (72.6%) were newly enrolled in SNAP. At follow-up, compared with baseline, participants were less likely to report food insecurity (83.1% vs 67.5%, P < .001), required less additional money for food ($73.33 vs $47.72 weekly, P < .001), were more likely to report excellent/very good health (26.8% vs 27.6%, P < .001), and were less likely to report cost-related medication nonadherence (24.1% vs 17.7%, P < .001) or use free food programs (82.6% vs 74.5%, P < .001). We found no changes in dietary intake.

CONCLUSION

SNAP uptake rates were high after the policy change. Policies that support older adults and adults with disabilities to enroll in or maintain SNAP benefits may improve health outcomes.

Associations between shopper impulsivity and cyclical food purchasing: Results from a prospective trial of low-income households receiving monthly benefits

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. Proposed interventions targeting the benefit cycle often focus on impulsive decision-making. However, it remains unclear whether shopper impulsivity is associated with food purchasing behavior. Using data from a prospective trial, we evaluate whether shopper impulsivity is associated with food purchasing behavior before and after households receive nutrition assistance. In this study, 249 low-income households in the Minneapolis-St. Paul, Minnesota, metropolitan area received monthly benefits for three months. Overall impulsivity and impulsivity subtraits of the primary shopper was assessed using the Barratt Impulsiveness Scale-11. Both total food expenditures and expenditures for two specific categories (fruits and vegetables, and foods high in added sugar) were evaluated. Generalized estimating equations were used to model household expenditures as a function of week since benefit distribution, impulsivity, and their interaction. Results showed that during the benefit period, food expenditures were cyclical and patterned by impulsivity. Shoppers with greater overall impulsivity spent $40.62 more in week 1 (p < 0.001). While more impulsive shoppers spent more on foods high in added sugar throughout the month (p < 0.05 for all weeks), no patterns were observed for fruits and vegetables. These findings suggest that greater impulsivity exacerbates cyclical food purchasing behavior. The impact of shopper impulsivity is especially notable for expenditures on foods high in added sugar. SNAP educational interventions to mitigate the benefit cycle may be strengthened by focusing on more impulsive shoppers and on strategies to reduce impulsive purchases of foods high in added sugar.

Trends in cyclical food expenditures among low-income households receiving monthly nutrition assistance: results from a prospective study

OBJECTIVE

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. However, to date, no study has evaluated trends in food expenditures before and after households receive benefits using prospective data, and whether these trends vary by household characteristics.

DESIGN

Generalised estimating equations were used to model weekly household food expenditures during baseline (pre-benefit) and intervention months by vendor (restaurants and food retailers). Food retailer expenditures were further evaluated by food category (fruits and vegetables and foods high in added sugar). All expenditures were evaluated by household composition, demographics and economic means.

SETTING

Minneapolis-St. Paul, Minnesota, metropolitan area.

PARTICIPANTS

Low-income households (n 249) enrolled May 2013-August 2015.

RESULTS

Weekly food retailer expenditures did not vary during baseline (pre-benefit), but demonstrated a cyclical pattern after households received benefits across all household characteristics and for both food categories, particularly for fruits and vegetables. Households with greater economic resources spent more throughout the month compared with those with fewer resources. Households with lower food security status experienced more severe fluctuations in spending compared with more food secure households.

CONCLUSIONS

Cyclical food purchasing was observed broadly across different household characteristics and food categories, with notable differences by household economic means and food security status. Proposed SNAP policy changes designed to smooth food expenditures across the benefit month, such as increased frequency of benefit distribution, should include a focus on households with fewest resources.

Supplemental Nutrition Assistance Program Participation Improves Children's Health Care Use: An Analysis of the American Recovery and Reinvestment Act's Natural Experiment

OBJECTIVE

To examine the impact of increased Supplemental Nutrition Assistance Program (SNAP) benefit levels as provided by the American Recovery and Reinvestment Act (ARRA) beginning in April 2009 on the health care use and health care needs of participating children.

METHODS

Difference-in-differences analysis compared changes in health care use and needs between children in SNAP-eligible households and those in low-income but SNAP-ineligible households before and after ARRA's implementation, using data from the nationally representative National Health Interview Survey (NHIS). Survey respondents reported on children's health care use and outstanding health care needs. Our sample included approximately 38,500 children in low-income households who completed the core NHIS, and a subsample of 15,000 sample children who reported additional information.

RESULTS

Approximately 6% of low-income children had delayed care due to cost. Three percent and 4% of children in low-income households and low-income single-parent households, respectively, reported needing health care but not being able to afford it. The increase in SNAP benefits was associated with a 65% reduction in outstanding medication needs due to affordability among SNAP-eligible children, relative to low-income, ineligible children. There was also a reduction in the likelihood that children had seen a general doctor in the last year. Among children in single-parent households, SNAP benefit expansion was associated with a 3.2 percentage point decrease in needing but not being able to afford health care.

CONCLUSIONS

Findings suggest that even a small increase in household resources leads to reductions in outstanding health care needs due to affordability, particularly among children.

Association of Work Requirements With Supplemental Nutrition Assistance Program Participation by Race/Ethnicity and Disability Status, 2013-2017

IMPORTANCE

Increased work requirements have been proposed throughout federal safety net programs, including the Supplemental Nutrition Assistance Program (SNAP). Participation in SNAP is associated with reduced food insecurity and improved health.

OBJECTIVES

To determine whether SNAP work requirements are associated with lower rates of program participation and to examine whether there are racial/ethnic disparities or spillover effects for people with disabilities, who are not intended to be affected by work requirements.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative, pooled cross-sectional study examined how changes in SNAP work requirements at state and local levels in the US are associated with changes in food voucher program participation. The study combined information on state and local SNAP work requirements with repeated cross-sections from the 2012 through 2017 American Community Survey (with outcomes covering 2013 to 2017). The analytical approaches were based on difference-in-difference and triple-difference methods, after controlling for other economic and social factors. The sample included low-income adults without dependents, stratified by racial/ethnic group and disability status. The study also included parents who would otherwise meet work requirement criteria as a comparison group to estimate triple-difference models. This accounted for otherwise unobserved factors affecting trends in SNAP participation within local areas. Data were analyzed from January 2019 through March 2020.

EXPOSURE

Residence in areas where SNAP work requirements apply.

MAIN OUTCOMES AND MEASURES

The primary outcome is SNAP participation measured by whether anyone in the household received food vouchers at any point over the prior 12 months.

RESULTS

The final analytical sample included 866 000 low-income adults (weighted mean [SE] age, 33.6 [0.01] years; 42.5% [SE, 0.07%] men). The racial/ethnic breakdown was 56.5% (SE, 0.07%) non-Hispanic white respondents, 19.4% (SE, 0.06%) non-Hispanic black respondents, 17.7% (SE, 0.06%) Hispanic respondents, 2.5% (SE, 0.02%) Asian respondents, and 3.9% (SE, 0.03%) respondents of other or multiple races. In final triple-difference models, work requirements were associated with a 4.0 percentage point decrease in participation (95% CI, -0.048 to -0.032; P < .001) for childless adults without disability, equivalent to a 21.2% reduction in SNAP participation (95% CI, -25.5% to -17.0%). For childless adults with disability, work requirements were associated with a 4.0 percentage point reduction (95% CI, -0.058 to -0.023; P < .001), equivalent to 7.8% fewer SNAP participants with disability (95% CI, -11.2% to -4.4%). When the final models were stratified by race/ethnicity, benefit reductions were larger for non-Hispanic black adults (7.2 percentage points; 95% CI, -0.092 to -0.051; P < .001) and Hispanic adults (5.5 percentage points; 95% CI, -0.072 to -0.038; P < .001) than for non-Hispanic white adults (2.6 percentage points; 95% CI, -0.035 to -0.016; P < .001).

CONCLUSIONS AND RELEVANCE

Because of the association of SNAP with food security and health, work requirements that lead to benefit loss may create nutritional and health harm for low-income Americans. These findings suggest that there may be racially disparate consequences and unintended harm for those with disability.

Hunger pains? SNAP timing and emergency room visits

This project uses quasi-random assignment of SNAP receipt dates linked to Medicaid healthcare records to examine whether ER use is affected by the timing of benefits. We find an increase in ER usage at the end of the benefit month, but only among older recipients. The estimated effect is much larger when the end of the benefit cycle coincides with the end of the calendar month, which is when other transfer payments are also depleted. This suggests that within this older group, increased food insecurity leads to increased ER utilization. Further, we find that the share of ER visitors that received SNAP benefits on the day of their ER visit is 3.1% lower than in the SNAP population. This is consistent with benefit receipt altering household behaviors and routines (notably, we observe, by increasing shopping), which may crowd out healthcare utilization. This particular effect is present across all age groups, although the magnitude is smallest for children.

Administrative Churn in SNAP and Health Care Utilization Patterns

BACKGROUND

Administrative churn occurs when a household exits the Supplemental Nutrition Assistance Program (SNAP) and then returns to the program within 4 months. Although a number of studies have examined health care utilization patterns related to Medicaid administrative churn less is known about health care utilization patterns among Medicaid-insured SNAP enrollees.

OBJECTIVES

To investigate the characteristics and health care utilization patterns of Medicaid insured SNAP participants who experience SNAP administrative churn.

RESEARCH DESIGN

Retrospective cohort study using 2010-2013 SNAP benefit data from the state of Missouri linked to Medicaid claims data for the same time period. Individual fixed effect regression analysis was used to investigate differences in health care claims for churners and nonchurners across various health care settings.

SUBJECTS

Missouri residents ages 18-64 who were Medicaid-insured SNAP enrollees.

MEASURES

Inpatient, outpatient, emergency department (ED), and pharmacy claims, and churn status.

RESULTS

Half of our sample (49.63%) experienced administrative churn. In the descriptive analyses, churners had fewer claims for prescription drugs than nonchurners (25.42% vs. 30.47%), but more claims for ED visits (3.79% vs. 2.74%). Adjusting for individual fixed characteristics, inpatient claims occurred with more frequency during periods of churn than while on SNAP, whereas ED, outpatient, and pharmacy claims occurred with less frequency during periods of churn than while on SNAP.

CONCLUSIONS

SNAP administrative churn was very common among our study sample. Given that health care utilization patterns varied for churners compared with nonchurners, it is important that researchers and public health professionals not assume stable SNAP receipt among participants.

Alternatives to SNAP: Global Approaches to Addressing Childhood Poverty and Food Insecurity

The Supplemental Nutrition Assistance Program (SNAP) in the United States is a key element of the nation's safety net. Yet, 12.5 million US children live in households that experience food insecurity, despite national spending of $65 billion on SNAP alone.In analyses integrating data from the 36 Organisation for Economic Co-operation and Development (OECD) countries, we found that child poverty and food insecurity are much higher in the United States than in most of the other OECD countries. The United States has higher total social spending than other OECD countries, but a lower rate of spending on children and families. This international comparison suggests that potentially effective solutions implemented in other countries might help further alleviate US childhood poverty and food insecurity.Broadly, we recommend increasing investments in families with children, particularly low-income families. Our specific recommendations include increasing SNAP benefits, establishing additional benefits to support low-income families with young children, and implementing a universal child allowance. Achieving substantial reductions in child poverty and food insecurity will require overcoming many challenges, including the current US political climate, a national history of underinvestment in social programs, a lack of political will, and a culture of structural racism.

Recommendations From SNAP Participants to Improve Wages and End Stigma

We present views of the Supplemental Nutrition Assistance Program (SNAP) from the perspective of participants. We are SNAP participants and academic researchers who have worked together for 11 years to understand, explain, and address food insecurity.SNAP is ensnared in much larger problems in US society related to the stigmatization of people who are poor and a lack of appreciation for the value and skills of their work. We encourage the public health community to think beyond SNAP, focus more assertively on wages and work supports, and replace our means-tested safety net with a new system of universal income that promotes equity, inclusion, and health for all.Although we offer recommendations to improve SNAP, the goal of most SNAP recipients has always been to move beyond the need for this program. The public health community can take the lead in finding more egalitarian, dignified, and effective ways to address poverty and food insecurity.

Chronic disease self-management within the monthly benefit cycle of the Supplemental Nutrition Assistance Program

OBJECTIVE

The present study explored chronic disease management over the monthly benefit cycle among primary food shoppers from households receiving Supplemental Nutrition Assistance Program (SNAP) benefits in Philadelphia, PA, USA.

DESIGN

In-depth interviews, participant observation and surveys were conducted with the primary food shopper of SNAP households.

SETTING

Interviews and surveys were conducted in a clinical setting at Children's Hospital of Philadelphia, at participants' homes, and in food procurement settings including grocery stores, food pantries and soup kitchens.

PARTICIPANTS

Eighteen adults who received SNAP; five with a diet-related chronic condition, five managing the chronic condition of a family member and thirteen with overweight or obesity.

RESULTS

All households had at least one member with a chronic disease or condition. Households reported that the dietary demands of managing chronic illnesses were expensive and mentally taxing. Food and financial shortfalls at the end of the benefit cycle, as well as reliance on charitable food assistance programmes, often had negative impacts on chronic disease self-management.

CONCLUSIONS

Drawing from nearly 50 h of in-depth qualitative interviews with SNAP participants, the study highlights the dual cognitive burden of poverty and chronic disease and elucidates the particular challenges of food procurement and maintenance of diet quality throughout the benefit month faced by SNAP households with diet-related chronic diseases. Interventions targeted at reducing the cost of medically appropriate, healthy foods may help to improve chronic disease self-management within SNAP populations.