Implementation Matters: Lessons From Iowa Medicaid’s Healthy Behaviors Program

Food Insecurity Is Prevalent in Iowa's Medicaid Expansion Population

BACKGROUND

Food insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations.

OBJECTIVE

Our objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa's Medicaid expansion population.

DESIGN

We conducted a cross-sectional telephone survey between March and May of 2019.

PARTICIPANTS

Our sample was drawn from Medicaid members enrolled in Iowa's expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample.

MAIN OUTCOME MEASURE

Our main outcome was whether a respondent's household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool.

STATISTICAL ANALYSES PERFORMED

We weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors.

RESULTS

The estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity.

CONCLUSIONS

Our findings show that food insecurity is prevalent in Iowa's Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access.

ABBREVIATIONS

Iowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP).

Iowa's Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012-17

Health behavior incentive programs are increasingly common in Medicaid programs nationwide. Iowa's Healthy Behaviors Program (HBP) requires Medicaid expansion enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums to avoid disenrollment. The extent to which the program reduces the use of hospital-based care and lowers health care spending is unknown. Using data for 2012-17 from Medicaid and for 2014-17 from HBP, we evaluated changes in use and spending associated with HBP participation. Compared to nonparticipants, HBP participants were less likely to have an emergency department visit or be hospitalized (by 9.6 percentage points and 2.8 percentage points, respectively) but had higher total health care spending ($1,594). Meanwhile, Iowa's Medicaid expansion was associated with increased use and spending independent of HBP participation-that is, applying to both participants and nonparticipants. Overall, our findings suggest that the HBP was associated with substantial reductions in hospital-based care but increased health care spending.