A Qualitative Study of Diverse Experts' Views about Barriers and Strategies to Improve the Diets and Health of Supplemental Nutrition Assistance Program (SNAP) Beneficiaries

The Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program, currently serves 44.7 million Americans with a budget of $75 billion in 2011. This study engaged leading experts for in-depth, semi-structured interviews to explore their opinions concerning the existing challenges and barriers to eating nutritiously in SNAP. Experts also proposed strategies for improving nutritional status among SNAP recipients. Twenty-seven individuals were interviewed from advocacy, government, industry, and research organizations. Interviews were recorded, transcribed, coded, and analyzed for thematic content. The high cost of nutrient-rich foods, inadequate SNAP benefits, limited access to purchasing healthy foods, and environmental factors associated with poverty were identified as barriers that influence nutrition among low-income households in the United States. Six themes emerged among respondents from diverse sectors about how to address these challenges, including providing SNAP participants with incentives to purchase nutrient-rich food consistent with the 2010 Dietary Guidelines for Americans, restricting the purchase of nutrient-poor foods and beverages with program benefits, modifying the frequency of SNAP benefit distribution, enhancing nutrition education, improving the SNAP retailer environment, and increasing state and federal level coordination and consistency of program implementation. Given the recent dramatic increase in SNAP enrollment, policymakers must address existing barriers as well as consider new strategies to improve nutrition policies in SNAP so that the program can continue to address food insecurity needs as well as provide a healthful diet for SNAP beneficiaries.     

Change in Employment Status Due to the COVID-19 Pandemic,SNAP Participation,and Household Food Insecurity among Black and Latino Adults in Illinois

The onset of the COVID-19 pandemic resulted in record-high unemployment rates. Black and Latino adults experienced disproportionately higher rates of unemployment. We aimed to examine associations between pandemic-related employment status change and household food insecurity among an economically diverse sample of Black and Latino adults in Illinois during the early months of the COVID-19 pandemic. Furthermore, we evaluated the significance of Supplemental Nutrition Assistance Program (SNAP) participation to determine if it modified associations. We analyzed cross-sectional data collected from 1,809 Black and Latino adults in two waves: May 2020 and June/July 2020. Participants listed their change in employment status as “lost job entirely”, “employed, but paid hours reduced”, “employed, but anticipate job lost”, or “no change”. Participants self-reported their SNAP status and completed the USDA’s six item U.S. Food Security Module to report household food security status. We used logistic regression to assess the significance of associations after controlling for socio-demographics. Approximately 15.5% of participants lost their job entirely, 25.2% were SNAP participants, and 51.8% reported low food security (LFS). All changes in employment were significantly associated with increased odds of LFS after adjusting for socio-demographics. SNAP participants who lost their job had higher odds of LFS (OR: 4.69; 95% CI: 2.69–8.17) compared to non-participants who lost their job (OR: 2.97; 95%: 1.95–4.52). In summary, we observed strong associations between changes in employment and household food insecurity, particularly among SNAP participants, which underscores the pandemic’s impact on low-income and minority populations.     

Caloric Beverage Intake Among Adult Supplemental Nutrition Assistance Program Participants

Objectives. We compared sugar-sweetened beverage (SSB), alcohol, and other caloric beverage (juice and milk) consumption of Supplemental Nutrition Assistance Program (SNAP) participants with that of low-income nonparticipants.Methods. We used 1 day of dietary intake data from the 2005–2008 National Health and Nutrition Examination Survey for 4594 adults aged 20 years and older with household income at or below 250% of the federal poverty line. We used bivariate and multivariate methods to compare the probability of consuming and the amount of calories consumed for each beverage type across 3 groups: current SNAP participants, former participants, and nonparticipants. We used instrumental variable methods to control for unobservable differences in participant groups.Results. After controlling for observable characteristics, SNAP participants were no more likely to consume SSBs than were nonparticipants. Instrumental variable estimates showed that current participants consumed fewer calories from SSBs than did similar nonparticipants. We found no differences in alcoholic beverage consumption, which cannot be purchased with SNAP benefits.Conclusions. SNAP participants are not unique in their consumption of SSBs or alcoholic beverages. Purchase restrictions may have little effect on SSB consumption.People in the Unites States consume about 20% of their calories from beverages, a share that has increased greatly over recent decades.1 Calories from beverages may be less satiating than calories from food and may therefore contribute to weight gain.2–5 Calories from sugar-sweetened beverages (SSBs) may be particularly problematic because they provide little if any essential nutrients. Policies suggested or enacted to reduce SSB consumption include taxing SSB purchases6–9 and restricting the size of SSBs sold by food service establishments. Most recently, the discussion has moved to whether participants in the Supplemental Nutrition Assistance Program (SNAP) should be prohibited from using benefits to purchase SSBs. SNAP provides nutrition assistance to low-income individuals and families through electronic benefit transfer cards that can be used to purchase food at authorized food retailers. SNAP benefits can be used to purchase almost all foods, with the exceptions of hot foods or food that will be eaten in the stores, alcoholic beverages and tobacco products.New York City requested a waiver from the Food and Nutrition Service of the US Department of Agriculture to restrict the use of SNAP benefits for purchases of some SSBs10 but was denied. Several high-profile commentators argued that the SNAP program may be subsidizing obesity and should be modified to encourage greater consumption of healthy foods and reduced consumption of empty calories such as SSBs.11,12 Others have argued that such restrictions could increase administrative costs but would have little impact on consumption patterns because most participants’ SNAP benefit only covers a portion of the household’s total food spending, and they could just use their cash food budgets to purchase SSBs.13 It has also been argued14 that imposing restrictions on only 1 part of the population is unfair when consumption of SSBs and obesity are fairly widespread among all Americans. Restrictions on SNAP purchases could have unintended consequences, such as reducing participation or substitution with other energy-dense foods.Despite the prominent appeals to restrict SNAP participants’ purchases, little evidence has shown that SNAP participants’ SSB consumption is different from that of the average consumer or other low-income consumers. Using longitudinal data for a cohort of US youths, no differences were found between SNAP participants and otherwise similar nonparticipants in the frequency of consumption (not total calories) of soft drinks, 100% fruit juice, and milk.15 Purchases of different beverages at 1 chain grocery store in New England for a sample of families that participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program over a 2-year period showed that among the participants, those who also received SNAP benefits purchased a higher percentage of SSBs than did non-SNAP participants.16 This study did not consider all SNAP households (or any other low-income households that did not participate in either SNAP or the Special Supplemental Nutrition Program for Women, Infants, and Children); examined beverage purchases at only 1 grocery store chain in New England; did not consider beverage purchases at bars, restaurants, or other food retailers; and did not consider beverage intake among household members. Both of these studies examined only a segment of all SNAP participants.Alcoholic beverages contribute a sizable share of total beverage calories for those who consume them. Alcoholic beverages cannot be purchased with SNAP benefits. If SSB purchases are restricted in SNAP, participants could use other resources to purchase SSBs, just as they may to purchase alcoholic beverages. Although there are important distinctions between SSBs and alcohol (e.g., tax rates, controlled points of purchase, limits on who can purchase, and some health benefits of moderate consumption), examining how alcohol consumption differs between participants and nonparticipants may provide insight into how a restriction on SSBs could affect purchases among SNAP participants.We used national-level data on individual beverage intake to investigate intake of SSBs, alcohol, and other caloric beverages (milk and juice) for SNAP participants and otherwise similar nonparticipants. After comparing average intake of these beverage types, we used regression to explore whether differences across participant groups are explained by differences in observable characteristics. We separately estimated the probability of consuming each beverage type and the total number of calories consumed among consumers of each beverage. We augmented our main estimates with instrumental variable estimates that account for self-selection of SNAP participants.     

Implementation of Wireless Terminals at Farmers’ Markets: Impact on SNAP Redemption and Overall Sales

Although farmers’ markets offer healthy foods for purchase, many lack the equipment necessary to process convenient, card-based transactions. We assessed the impact of providing wireless terminals to 5 markets on overall sales and redemption of Supplemental Nutrition Assistance Program (SNAP) benefits. Sales increased significantly at 4 of the 5 markets after implementation of the terminals, and overall sales increased above and beyond SNAP redemption alone. Implementation of wireless terminals may be important for improving the financial stability and accessibility of farmers’ markets.With the increased popularity of the “buy local” movement, demand is growing for venues selling locally grown foods, such as farmers’ markets.1–4 These venues offer the potential to expand access to fresh, healthy foods for a variety of consumers, in particular low-income consumers.5,6 Farmers’ markets, for example, can become certified to accept benefits from food assistance programs such as the Supplemental Nutrition Assistance Program (SNAP).7,8 However, barriers exist that limit the full use of such benefits.For instance, many farmers’ markets operate in temporary locations that lack electricity, making card-based transactions requiring plug-in terminals difficult to process.9,10 This can limit both the convenience of card-based purchasing for all consumers and accessibility of markets to SNAP participants. With the conversion of SNAP benefits from paper coupons to electronic benefit transfer (EBT) cards, SNAP redemption at markets dropped from $6.4 million in 1994 to $3.8 million in 1998.11 SNAP redemption has since increased, with more than $7.5 million in benefits redeemed in 2010.12 Despite this increase, only 0.01% of all SNAP benefits were redeemed at farmers’ markets that year.12In this pilot study, we investigated the impact of wireless terminal use on overall and EBT sales at farmers’ markets. We hypothesized that implementation of wireless terminals would increase SNAP redemption and overall sales at these markets.     

Self-Reported Use of Supplemental Nutrition Assistance Program Benefits to Purchase Soda in a Public Health Center Population: Los Angeles County,California, 2012

To better inform local program planning for the Supplemental Nutrition Assistance Program (SNAP), the Los Angeles County Department of Public Health used self-reported data from a public health center population to examine the prevalence of benefits used to purchase soda. We performed statistical analyses, including multivariable regression modeling, using data from a local health and nutrition examination survey. The survey response rate was 69% (n=1,503). More than one-third of survey participants reported receiving, or living in a household where someone receives, nutrition assistance benefits. When asked, 33% (n=170) reported using these benefits to purchase soda “sometimes” and 18% (n=91) reported “often” or “always,” suggesting that the use of program benefits to purchase soda was not uncommon in this subpopulation. These findings have meaningful policy and planning implications, as they contribute to ongoing dialogue about strategies for optimizing nutrition among SNAP recipients.In 2013, more than 46.5 million Americans participated in the Supplemental Nutrition Assistance Program (SNAP).¹ The federally funded SNAP is administered through an electronic benefit transfer (EBT) system, which allows participants to purchase food as authorized by the U.S. Department of Agriculture (USDA); cigarettes, alcohol, and hot food items meant to be consumed in the store are excluded.^2,3 Unlike other federally funded programs (e.g., Special Supplemental Program for Women, Infants, and Children and the National School Lunch Program), there are currently no nutritional requirements for foods purchased with benefits from SNAP.^3–5The stated goals of SNAP are to safeguard the health and well-being of the U.S. population and to raise levels of nutrition in low-income households.⁶ Citing a need to better achieve these goals, several states across the country have unsuccessfully sought permission from the USDA to implement nutrition standards that would limit the purchase of foods with minimal nutritional value (e.g., soda and potato chips) using SNAP benefits.⁷ While most conversations to date have focused on the potential health benefits, the ethical concerns surrounding restricting choice, and the barriers to implementing such food restrictions, a paucity of data on benefits use is available to inform the debate and policy development.^4,8–11 We contribute to closing this gap in knowledge by examining the prevalence, frequency, and characteristics of adults who use SNAP benefits to purchase soda.     

Online Grocery Shopping Knowledge,Attitudes, and Behaviors Among SNAP Participants

ObjectiveTo inform policy proposals to allow online grocery shopping with Supplemental Nutrition Assistance Program (SNAP) benefits by examining relevant behaviors, knowledge, and attitudes of SNAP recipients.MethodsThis qualitative study used a purposive recruitment strategy to conduct 4 1-hour focus groups in Las Cruces, NM. Participants were SNAP recipients who do the grocery shopping for their families. Focus groups were video and audio recorded, transcribed, and coded.ResultsFew participants had shopped for groceries online, and participants were generally uninterested in grocery shopping online. Identified barriers were cost, quality control for perishable foods in particular, and distrust of the overall process. Participants expressed interest in suggested services aimed at increasing the benefits of shopping online.Conclusions and ImplicationsSNAP recipients in this study have not adopted online grocery shopping for various reasons. Additional research could inform policy by investigating which participants would benefit from using SNAP benefits online and strategies for facilitating use.     

Connecting Families at Risk for Food Insecurity With Nutrition Assistance Through a Clinical-Community Direct Referral Model

ObjectiveTo assess the feasibility of a clinical-community direct referral model to enroll eligible households in the Supplemental Nutrition Assistance Program (SNAP).MethodsPediatric clinics screening for food insecurity (n = 27) invited families experiencing food insecurity to participate in a direct referral to a local organization that assists with SNAP applications. A food stamp specialist telephoned participants to determine SNAP eligibility, assist with the application, and/or provide other supports. Referrals, eligibility determination, enrollment, and estimated benefits were tracked.ResultsA total of 486 families were referred to the community partner; 72% (n = 351) were successfully contacted by a food stamp specialist, with 17% (n = 83) applying for SNAP benefits. Another 16% (n = 79) were already enrolled in SNAP but received an additional service.Conclusions and ImplicationsThis referral model was feasible and increased the number of families who received nutrition assistance. This approach could be adapted for other health-related social needs.     

Perceptions of SNAP and Stocking Standards: A Qualitative Study of California Small Food Store Owners and Managers

The Supplemental Nutrition Assistance Program (SNAP) is critical to alleviating food insecurity, but low diet quality among program participants is a concern. Nutrition-related interventions have focused on SNAP-authorized food retailers, but the perspectives of small food store owners and managers have not been represented in national policy discussions. This study aimed to explore the opinions of store owners/managers of SNAP-authorized small food stores about their overall perceptions of the program and the stricter stocking standards previously proposed in 2016. We conducted in-depth, semi-structured interviews with 33 small food store owners and managers in San Francisco and Oakland, California in 2016. Interviews were analyzed for thematic content using the general inductive approach. Four themes emerged from owners/managers’ discussion of their overall perceptions of SNAP: the beneficial impact of SNAP on their business, how SNAP enables them to connect with the broader community, the importance of SNAP in preventing hunger, and the nutrition-related struggles that SNAP participants face. Store owners/managers had a generally favorable response towards the proposed stricter stocking standards. Additional themes discussed pertained to the concern about whether stocking changes would lead SNAP participants to purchase more healthful food and some logistical challenges related to sourcing and storing perishable foods.     

State variations in supplemental security income enrollment for children and adolescents.

OBJECTIVES: The purpose of this study was to determine the effects of poverty, program generosity, and health on state variations in enrollment of children and adolescents in the Supplemental Security Income (SSI) program during recent program expansions. METHODS: The relationship of state SSI rates for 1989 and 1992 to child poverty, health, and program generosity were determined by multiple regression. RESULTS: The mean percentage of children enrolled grew from 0.36% (1989) to 0.75% (1992). Poverty rates accounted for 78% of the variance among states in 1989 and 53% in 1992. Other indicators accounted for little variance. CONCLUSIONS: Differences in state poverty levels explained almost all variation in SSI enrollment.     

Associations between food insecurity, supplemental nutrition assistance program (SNAP) benefits, and body mass index among adult females

Obesity disproportionately affects low-income and minority individuals and has been linked with food insecurity, particularly among women. More research is needed to examine potential mechanisms linking obesity and food insecurity. Therefore, this study's purpose was to examine cross-sectional associations between food insecurity, Supplemental Nutrition Assistance Program (SNAP) benefits per household member, perceived stress, and body mass index (BMI) among female SNAP participants in eastern North Carolina (n=202). Women were recruited from the Pitt County Department of Social Services between October 2009 and April 2010. Household food insecurity was measured using the validated US Department of Agriculture 18-item food security survey module. Perceived stress was measured using the 14-item Cohen's Perceived Stress Scale. SNAP benefits and number of children in the household were self-reported and used to calculate benefits per household member. BMI was calculated from measured height and weight (as kg/m²). Multivariate linear regression was used to examine associations between BMI, SNAP benefits, stress, and food insecurity while adjusting for age and physical activity. In adjusted linear regression analyses, perceived stress was positively related to food insecurity (P<0.0001), even when SNAP benefits were included in the model. BMI was positively associated with food insecurity (P=0.04). Mean BMI was significantly greater among women receiving <$150 in SNAP benefits per household member vs those receiving ≥$150 in benefits per household member (35.8 vs 33.1; P=0.04). Results suggest that provision of adequate SNAP benefits per household member might partially ameliorate the negative effects of food insecurity on BMI.     

SNAP and Cardiometabolic Risk in Youth

Increasing numbers of children and adolescents have unhealthy cardiometabolic risk factors and show signs of developing metabolic syndrome (MetS). Low-income populations tend to have higher levels of risk factors associated with MetS. The Supplemental Nutrition Assistance Program (SNAP) has the potential to reduce poverty and food insecurity, but little is known about how the program affects MetS. We examine the relationship between SNAP and the cardiometabolic risk factors in children and adolescents using regression discontinuity to control for unobserved differences between participants and nonparticipants. We find that SNAP-eligible youth who experience food insecurity have significantly healthier outcomes compared to food-insecure youth just over the income-eligibility threshold. Our findings suggest that SNAP may be most beneficial to the most disadvantaged households. Policy makers should consider the broad range of potential health benefits of SNAP.     

Supplemental nutrition assistance program and body weight outcomes: the role of economic contextual factors

We explored the extent to which economic contextual factors moderated the association of Supplemental Nutrition Assistance Program (SNAP) participation with body mass index (BMI) among low-income adults whose family income (adjusted for family size) is less than 130% of the federal poverty guideline. We drew on individual-level data from the Panel Study of Income Dynamics in the United States, including three waves of data in 1999, 2001, and 2003. Economic contextual data were drawn from the American Chamber of Commerce Researchers Association for food prices and Dun & Bradstreet for food outlet measures. In addition to cross-sectional estimation, a longitudinal individual fixed effects model was used to control for permanent unobserved individual heterogeneity. Our study found a statistically significant joint moderating effect of the economic contextual factors in longitudinal individual fixed effects model for both women (BMI only) and men (both BMI and obesity). For both women and men, SNAP participants' BMI was statistically significantly lower if they faced increased numbers of available supermarkets/grocery stores in the longitudinal model. A simulated 20% reduction in the price of fruits and vegetables resulted in a larger decrease in BMI among SNAP participants than non-participants for women and men, whereas a simulated 20% increase in the availability of supermarkets and grocery stores resulted in a statistically significant difference in the change in BMI by SNAP participation for women but not for men. Policies related to economic contextual factors, such as subsidies for fruits and vegetables or those that would improve access to supermarkets and grocery stores may enhance the relationship between SNAP participation and body mass outcomes among food assistance program participants.     

The Supplemental Nutrition Assistance Program,Food Insecurity,Dietary Quality,and Obesity Among US Adults

Objectives. We examined whether Supplemental Nutrition Assistance Program (SNAP) participation changes associations between food insecurity, dietary quality, and weight among US adults.Methods. We analyzed adult dietary intake data (n = 8333) from the 2003 to 2010 National Health and Nutrition Examination Survey. Bivariate and multivariable methods assessed associations of SNAP participation and 4 levels of food security with diet and weight. Measures of dietary quality were the Healthy Eating Index 2010, total caloric intake, empty calories, and solid fat; weight measures were body mass index (BMI), overweight, and obesity.Results. SNAP participants with marginal food security had lower BMI (1.83 kg/m²; P < .01) and lower probability of obesity (9 percentage points; P < .05). SNAP participants with marginal (3.46 points; P < .01), low (1.98 points; P < .05), and very low (3.84 points; P < .01) food security had better diets, as illustrated by the Healthy Eating Index. Associations between SNAP participation and improved diet and weight were stronger among Whites than Blacks and Hispanics.Conclusions. Our research highlights the role of SNAP in helping individuals who are at risk for food insecurity to obtain a healthier diet and better weight status.Food insecurity, broadly defined as having limited access to adequate food,1 is associated with increased stress levels and reduced overall well-being.2 In addition, food insecurity has been shown to diminish dietary quality and affect nutritional intake and has been associated with chronic morbidity (e.g., type 2 diabetes, hypertension) and weight gain.1,3–5 In 2012, approximately 14.5% of US households (17.6 million households) experienced food insecurity, of whom 5.7% (7.0 million households) experienced very low food security (i.e., reduction in food intake).6 The Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, is the largest government assistance program in the United States and seeks to alleviate food insecurity in US households.7 SNAP has the potential to mitigate the adverse effects of food insecurity on health outcomes not only through attenuating food insecurity but also by enhancing the dietary quality of its participants.8,9Although cross-sectional studies have found no significant differences in food insecurity levels between SNAP participants and nonparticipants,10,11 in a longitudinal study, Nord observed a 28% reduction in the odds for very low food security among households that remained on SNAP throughout the year relative to those who left before the last 30 days of the year.12 In addition, studies by Leung and Villamor13 and Webb et al.14 found that independent of food insecurity, SNAP participation is associated with the increased likelihood of obesity, and other studies have observed lower dietary quality specifically among SNAP participants.15,16 Kreider et al. used partial identification bounding methods to take into account the endogenous selection and misreporting of SNAP enrollment and found that SNAP reduced the prevalence of food insecurity, poor general health, and obesity among children.17Thus, the interrelationships among SNAP participation, food insecurity, dietary quality, and weight status warrant further investigation to inform SNAP programming, policy, and outreach to ultimately improve the health and well-being of SNAP participants. We explored these relationships in data from the National Health and Nutrition Examination Survey (NHANES) over multiple years. We aimed to determine mitigating effects SNAP participation might have on the association of food insecurity with dietary quality and obesity among a nationally representative sample of US adults.     

Household Supplemental Nutrition Assistance Program Participation is Associated With Higher Fruit and Vegetable Consumption

ObjectiveExamine whether differences were present by Supplemental Nutrition Assistance Program (SNAP) participation in dietary patterns, achievement of dietary recommendations, and food security for children (aged 7–18 years) receiving free/reduced-price school meals.MethodsCross-sectional study. Caregiver–child dyads at a pediatric clinic completed validated surveys. Food security, dietary patterns, and achievement of dietary recommendations were compared between child SNAP participants/nonparticipants.ResultsAmong 205 caregivers, 128 (62.4%) reported SNAP participation. Percentages of child SNAP participants/nonparticipants meeting recommendations were largely nonsignificantly different and overwhelmingly low. Supplemental Nutrition Assistance Program participants reported higher mean daily servings of vegetables (P = 0.01) and fruits (P = 0.01) than nonparticipants. Caregiver-reported household food security was not significantly different between SNAP participants and nonparticipants (P = 0.44).Conclusions and ImplicationsIn this study, child-reported fruit/vegetable intakes were significantly higher among SNAP participants than nonparticipants, suggesting child SNAP participants may experience small but noteworthy benefits related to fruit/vegetable consumption. Additional supports are needed to achieve dietary recommendations.     

Support for Policies to Improve the Nutritional Impact of the Supplemental Nutrition Assistance Program in California

The Supplemental Nutrition Assistance Program (SNAP) provides a vital buffer against hunger and poverty for 47.6 million Americans. Using 2013 California Dietary Practices Survey data, we assessed support for policies to strengthen the nutritional influence of SNAP. Among SNAP participants, support ranged from 74% to 93% for providing monetary incentives for fruits and vegetables, restricting purchases of sugary beverages, and providing more total benefits. Nonparticipants expressed similar levels of support. These approaches may alleviate the burden of diet-related disease in low-income populations.The Supplemental Nutrition Assistance Program (SNAP) aims to alleviate food insecurity and improve the health of low-income children and families.1 With a budget of $80 billion, SNAP currently serves 47.6 million Americans, including more than 20 million children.1,2Despite recent efforts to promote nutritious food options in SNAP,3,4 there are no established nutritional guidelines for SNAP-eligible foods.5 Obesity and diet-related disease disproportionately affect low-income individuals6–8; thus, public health advocates and researchers have urgently sought to identify policies that could bolster the nutritional influence of SNAP.9–12 So far, monetary incentives show promise: an evaluation of the US Department of Agriculture–funded Healthy Incentives Pilot showed that providing a $0.30 per SNAP dollar incentive for fruits and vegetables resulted in a 25% increase in their consumption levels.13The objective of this study was to identify strategies that would be perceived as most acceptable to improving the nutritional intake of SNAP participants, using a statewide sample of California adults, including an oversample of SNAP participants.     

Poorer Neuropsychological Performance Increases Risk for Social Services Among HIV-infected Individuals

HIV-Associated Neurocognitive Disorder (HAND) is a prevalent condition among persons with HIV resulting in cognitive impairments that may impact daily functioning. The relationship between neuropsychological (NP) test performance and functional status was investigated based on social services received (SSR) among 285 HIV-infected and 242 HIV-negative participants enrolled in the Hawai‘i Aging with HIV Cohort. HIV-infected participants scored significantly lower than the HIV-negative group on all measures of NP testing and also reported receiving SSR at a higher rate. Among HIV-infected participants, more SSR correlated with poorer overall global NP performance (ρ = −0.25, P < .001), as well as poorer performance in NP domains assessing psychomotor speed (ρ = −0.25, P < .001), and learning and memory (ρ = −0.19, P = .02). NP test performance did not correlate with the number of SSR among HIV-negative participants. Supplemental Security Income (SSI) was the most commonly utilized social service among HIV-infected. Receiving SSI was associated on multivariate analysis with poorer NP performance independent of lack of full time work, or nadir CD4 count. Poorer NP performance among HIV-infected individuals is associated with increased risk for social services. Interventions to address causes of cognitive dysfunction in this population may decrease demand for social services.     

The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon

BackgroundThe Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion.ObjectiveTo examine the association of the ACA expansion on health care access and utilization for adults ages 18–64 years who have qualified for Supplemental Security Income (SSI) in Oregon.MethodsWe used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits.ResultsThe Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon’s counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association.ConclusionsWe did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.     

SNAP Benefits: Can an Adequate Benefit Be Defined?

The Supplemental Nutrition Assistance Program (SNAP) increases the food purchasing power of participating households. A committee convened by the Institute of Medicine (IOM) examined the question of whether it is feasible to define SNAP allotment adequacy. Total resources; individual, household, and environmental factors; and SNAP program characteristics that affect allotment adequacy were identified from a framework developed by the IOM committee. The committee concluded that it is feasible to define SNAP allotment adequacy; however, such a definition must take into account the degree to which participants’ total resources and individual, household, and environmental factors influence the purchasing power of SNAP benefits and the impact of SNAP program characteristics on the calculation of the dollar value of the SNAP allotment. The committee recommended that the USDA Food and Nutrition Service investigate ways to incorporate these factors and program characteristics into research aimed at defining allotment adequacy.     

Massachusetts Inpatient Medicaid Cost Response to Increased Supplemental Nutrition Assistance Program Benefits

Objectives. To investigate the impact of an increase in Supplemental Nutrition Assistance Program (SNAP) benefits on Medicaid costs and use in Massachusetts.Methods. Using single and multigroup interrupted time series models, I examined the effect of an April 2009 increase in SNAP benefits on inpatient Medicaid cost and use patterns. I analyzed monthly Medicaid discharge data from 2006 to 2012 collected by the Massachusetts Center for Health Information and Analysis.Results. Inpatient costs for the overall Massachusetts Medicaid population grew by 0.55 percentage points per month (P < .001) before the SNAP increase. After the increase, cost growth fell by 73% to 0.15 percentage points per month (–0.40; P = .003). Compared with the overall Medicaid population, cost growth for people with the selected chronic illnesses was significantly greater before the SNAP increase, as was the decline in growth afterward. Reduced hospital admissions after the SNAP increase drove the cost declines.Conclusions. Medicaid cost growth fell in Massachusetts after SNAP benefits increased, especially for people with chronic illnesses with high sensitivity to food insecurity.People in 1 in 7 US households experience food insecurity,1 meaning they experience hunger, insufficient food, or concerns about having enough food.2 Food insecurity is associated with a large set of health problems for both children and adults.3–11 People with chronic illnesses, who usually have heightened costs of care, are both more likely to experience food insecurity12–14 and more vulnerable to its health effects.15 Understanding the contribution of this problem to health care utilization and costs, however, has been difficult with available data.16One approach to doing so is to look at the inverse question; that is, examining the effects of alleviating food insecurity. The Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamps Program) is the largest domestic antihunger program.17 Despite some methodological difficulties,18,19 SNAP has been shown to at least partially alleviate food insecurity for recipients,20,21 making it a good candidate for study. Unfortunately, changes to the program usually occur slowly, limiting the ability to detect broad changes in food insecurity levels and their potential impact on health. However, as part of the American Recovery and Reinvestment Act, maximum monthly SNAP allotments to beneficiaries were temporarily increased by 13.6% from April 2009 to October 2013.22 This larger change to the status quo provided a unique opportunity to examine the effects of alleviating food insecurity on recipients.I analyzed the relationship between the timing of the increase in SNAP benefits and patterns of health care utilization and costs. Massachusetts provided an ideal setting for this investigation. The Massachusetts Center for Health Information and Analysis collects detailed information on each admission to every hospital in the state, allowing analyses of both the general Medicaid population and those with chronic illnesses. Moreover, the state expanded Medicaid coverage as part of its health reform law in 2006, well before the April 2009 SNAP increase, and it passed a wide-ranging payment reform law that came into effect in 2012, well after the SNAP increase. Between these reforms was a time when economic growth was stagnant for low-income populations, even after the formal end of the Great Recession.23 This provided an ample study period from October 2006 to August 2012.     

The development of the Supplemental Nutrition Assistance Program enrollment accessibility (SNAP-access) score

BackgroundThe Supplemental Nutrition Assistance Program (SNAP) is a federal public benefit providing food assistance to millions of Americans. However, it is typically administered by states, creating potential variation in accessibility and transparency of information about enrollment for people with disabilities.ObjectiveTo develop and demonstrate the use of a method to assess the accessibility and transparency of information about the disability-inclusive process and practices of SNAP enrollment.MethodsCross-sectional data was collected from SNAP landing and enrollment webpages from all 50 U.S. states, the District of Columbia, and New York City from June–August 2021. Based on principles of universal design and accessibility, scores were determined for each SNAP program across three areas: flexibility in the enrollment process (6 points), efficiency of finding information about enrollment on SNAP websites (6 points), and the accessibility of SNAP webpages (6 points). Total scores were the sum of these sub-categories (18 points maximum).ResultsOf the 52 SNAP programs assessed, mean scores were 10.66 (SD = 2.51) for the total score, 2.67 (SD = 0.91) for flexibility in the enrollment process, 3.32 (SD = 1.19) for efficiency of finding information about enrollment on SNAP websites, and 4.67 (SD = 1.72) for the accessibility of SNAP webpages. No programs received the maximum flexibility score (6 points) on flexibility, 2 programs received the maximum on efficiency, and 31 programs the maximum on accessibility.ConclusionsWe found differences in the accessibility, flexibility, and efficiency of SNAP program enrollment information available on SNAP websites and outline room for improvement across all three of these areas.