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- We're gonna talk about
food insecurity today
and we're gonna focus,
after I give you a broad
overview of food insecurity,
and why we should care
and why it has anything to do with health,
we're gonna focus on SNAP
as a model intervention
for one way in which we
address health outside
of the hospital walls without, generally,
really realizing that we're doing it.
So, I do not have any
conflicts of interest.
We're gonna talk about
food insecurity and health,
we're gonna talk about the
impact of SNAP on health
and then if there's time and
there's interest in the room,
we'll talk about some of the recent
and proposed changes to the SNAP program
because I think it's
important to understand
that these political initiatives
have real implications
in the healthcare setting
even when they come under the term food
or under agriculture or
any of the other ways
that we generally conceptualize
them that isn't health.
So, we know that diet
is a cornerstone of care
for the most common chronic
diseases in the United States
and really I would argue
that some of the diseases
on this list are really
the epidemics of our day
which I say all the time
but maybe on, you know, March 13th 2020,
the epidemic of our day is coronavirus
but until this week, everybody would say
that diabetes and obesity
were really the epidemics
of our day
and in terms of morbidity and mortality,
diabetes and obesity are
really driving enormous changes
in the overall health of the
United States and the world.
Now, the problem with
diet being a cornerstone
of care is that we don't actually do most
of our diet decision-making
in an exam room
within a hospital or a clinic.
Really, no matter what
I say as a clinician,
you're gonna leave as
a patient my exam room
and you're gonna enter a world,
no matter what I tell you
about what you should be eating
and how you should be eating it,
you'll leave my exam room and
this is where you'll go to
because this is where everybody goes to.
This is what the food system looks like
in the United States.
It is populated cheap calories
that have no nutrients
and that give us an
overwhelming number of choices
that are heavily marketed
in beautiful colors
and designed to make
us want to pick them up
and purchase them at
a very low, low price.
And so, the question really
for us as clinicians is,
how can we make a meaningful
difference in the clinic
when we see our patients so infrequently
and for so little time?
And then they go out into a world
where the food system doesn't support any
of the eating habits that
we might suggest to you
as clinicians are good for you
and so, one of the elements
of this food system
that is not working well is
the element of affordability
and I'm gonna start with
a couple of definitions.
The most important definition
for today is the word food insecurity
and we define food
insecurity in distinction
to food security which the USDA defines
as access by all people at
all times to enough food
for an active, healthy life
and food insecurity is a household level
because people share the food
budget and decision-making
around what to eat as a household,
a household level economic
and social condition
of limited or uncertain
access to adequate food.
Now, in the United
States, this is different
than the way it is
conceptualized globally.
In the United States,
food insecurity is measured
as an economic measure.
It is about affordability.
Do you have enough money for
food or enough other resources
like SNAP benefits or
other benefits for food
and so, really we're talking
about affordability here
and if you can believe it,
one in nine U.S. households
are food insecure.
It's about 11% of the U.S. pop,
11% of all households
in the United States.
Now, this includes
about 6.8% of households
with low food security
and in these households,
the quality of food has diminished
in order to meet a tight food budget
but in general, the
quantity hasn't diminished
and we'll go into this in much
more depth in a few minutes
and then another 4.3% of U.S. households
in which both the quantity,
the quality of food has to diminish
and the quantity has to diminish
in order to meet a severely
constrained food budget
and so, one in nine U.S.
households, about 11.1%
but when we look across
different populations,
there is enormous variability
in food insecurity rates
and these are some of the
most important risk factors
for food insecurity,
about 17% of all households with children
in the U.S. are food insecure,
particularly if those
households are headed
by a single parent, if that woman,
if that head of household
is a single mother,
your risk of being food insecure
as a child is one in three
which is enormous.
If your income is low,
below 185% of the federal poverty level
and we use that 185% level generally
because above 185% people
are generally not eligible
for any federal nutrition benefits.
And then people living in
black or latino households are
at much higher risk of food insecurity
because the structures
and systems in place
for decades have not
supported food security.
If you are not yet convinced
that this is a common
condition in the U.S,
when we look back in time to
when the SNAP program was
called the Food Stamps program
and we just asked people
about history of exposure
to food stamps or SNAP,
the supplemental nutrition
assistance program,
about 50% of all children
and 90% of black children
in the U.S. will report
having been on food stamps
at some point during their childhood
and among adults about
50% will be on food stamps
at some point between
the ages of 20 and 65.
So, this is a very common experience.
The typical duration
of being on food stamps
or SNAP is very brief, about three months
but when you look overall at
people's life trajectories,
a very, very common experience.
So, I defined for you a few
minutes ago food insecurity
and I want to spend a minute
to make a distinction between
food insecurity and hunger.
The word hunger is defined
as a physical sensation,
the discomfort that you feel or the unease
that you feel when you haven't
had access to adequate food
and this is a sensation
that everybody feels.
Now, the literature has
really steered away entirely
from using the word hunger
and using the word food insecurity
for a couple of reasons,
because of a couple of advantages.
One is that many people who
by yours and my definition,
you would probably say is going hungry.
Many of those people
do not any longer feel
the physical sensation of hunger.
That sensation has become blunted
because of years or decades of exposure
to not having adequate food to eat
and the second reason is
because it isn't actually hunger
that is the problem in the context
of the development of obesity and diabetes
and other chronic diseases.
It is instead the coping
strategies that people employ
in order to avoid the
physical sensation of hunger.
And these coping strategies
are the same things
that you would probably think
about doing if I said to you,
"you have $4.90 to spend on food per day."
So, that's a typical dollar
value of a SNAP benefit,
food stamps benefit
in the United States
is about $4.90 per day.
If that were all that
you had to spend on food,
what would you do?
Well, you would probably
do the same things
that many other people do,
you might eat low cost foods
that tend to be nutrient
poor, energy dense.
You might eat very highly filling foods
that you know are gonna fill you up
and keep you full until the next day
or the next opportunity you have to eat.
You may concentrate dietary
intake on a few foods
that are very rewarding,
comforting for you
but again that fill you up,
you may avoid food waste among
yourself or your children
and many people have
experienced this as a child
in the context of food insecurity
and often not in the
context of food insecurity
and then binging when food
is available in anticipation
of an episode of food
inadequacy in the future.
And we know that these are
highly adaptive in the short-term
because they keep you from going hungry
and keep you from losing weight
but when these coping
strategies are sustained
for years or decades or a lifetime,
which is a typical
pattern of food insecurity
in the United States we know
that they will predispose
you to obesity and diabetes
and other diet sensitive chronic diseases
and then once you're chronically ill,
it makes it that much more challenging
to manage your illness
because you still don't have access
to the healthy foods you need.
This is the real problem that
we're talking about here.
Now, I will say those are the advantages
of talking about food
insecurity and not hunger.
The disadvantage is
that the term blunts our
emotional response to this need
and so, we can have all of
these academic conversations
about food insecurity
without sometimes ever
really internalizing the fact
that 11.1% of households in
the United States aren't sure
that they're gonna have
enough money to feed everyone
in their family at the end of the month.
So, there are advantages
and disadvantages here.
When we take all of this together,
this is the way in which we think
about food insecurity impacting health.
If you start at the top of the slide here,
you live in a food insecure household,
you engage these coping strategies
and we've talked a little bit
about the nutritional strategies,
we'll talk about some of the
other ones in a few minutes.
Those coping strategies predispose you
to poor physical and mental health.
Once you have those diseases,
your healthcare expenditures go up
because having a disease is
expensive in the United States,
out of pocket healthcare expenditures
and trips to hospitals and
clinics make it more challenging
to maintain steady employment.
With decreased employment
comes decreased income
which puts increased pressure
on your household budget
which makes it more likely
that you're gonna live
in a food insecure household.
Now, the important thing about
this is that it's a circle
which means if we follow it
to its logical conclusion,
it's entirely possible
that food insecurity causes
poor physical and mental health
but it's also possible
and I've not yet proven
to you that it's not true
that it's just poor health
in the United States predisposes
people to food insecurity
and that may also be the case
although I hope to prove to you that it's,
that the circle, that
it really is a circle,
that it's running in both directions
and that people can get
caught up in a cycle
of food insecurity and poor health
in a way that builds on each other.
So, let's start by
talking about nutrition.
This is a complicated graph
but let me just take you
through the important parts of this.
What you see along the bottom
axis is how much it costs
for one calorie lets say of food
and what you see here
is the density of food.
What we're essentially saying
here is if I gave you $4.90
to spend on food today
and you are an economically
rational person
and you were academically motivated
and you went to the academic literature
or the library or Google Scholar
to try to figure out
how to spend those $4.90
and you are gonna do it
in a way that made sure
that you got your 1,800
or 2,000 calories per day,
then what you would do
as again an economically rational
person is you would spend
that $4.90 on oil, shortening, margarine,
sugar, bread, pasta and rice.
And then we wonder about associations
in the U.S. between
low income and obesity,
low income and diabetes
and you see all of these
lighter shaded squares
and triangles here,
these are all of our fruits and vegetables
which calorie for calorie
are way more expensive
than our more energy dense foods.
This graph here shows you
in the black line the
consumer price index for food
which basically is the average price
of an average market of goods
for the average consumer
in the United States.
You can see it's been rising a little bit
over the last 30, 40 years.
We have more recent data
but it looks the same
but what you can see is
exerting the upward pressure
on this CPI for food
in the black line is our
fresh fruits and vegetables.
These are becoming relatively
more expensive over time
while the things that are
holding the CPI for food down
in these red and yellow lines
here are our carbonated drinks
or are for in most cases our
sugar sweetened beverages
and our nonalcoholic beverages.
So, fruits and vegetables are getting
more expensive over time.
This graph shows you the percentage
of your total household budget
that you're likely to be spending on food
depending on what income
quintile you are in now.
So, wealthy households in
the U.S. spend about 5%
of their total household income on food,
the lowest income quintile
in the U.S. spends 30%
of their entire household budget on food.
And the reason why this is important is
because it gives very little opportunity
to make substitutions
within the food budget
towards more expensive
but healthier items.
As a matter of fact, a couple of years ago
in a very well done study,
these researchers documented
that the diet recommended
by the USDA, the least expensive
diet considered nutritious,
the thrifty food plan diet would
require a low income family
to spend up 70% of their
entire household food budget
on fruits and vegetables.
And the challenge with that
again is it's healthy, yes,
but it doesn't actually
give you enough calories
to maintain your energy needs
and if you increased
your dietary potassium,
potassium coming substantially
from fresh fruits
and from fruits and vegetables
to meet the USDA dietary
guidelines would add
an additional $380
to the average consumer's
annual food costs.
So, what can you do about that?
Invest in saturated fat and sugar.
Now, I just want to quickly
add here that when you talk
to a typical low income
consumer about the cost of food,
it quickly becomes apparent
that the cost of food isn't
only about the amount of money
that you're putting down
in the cashier aisle,
the cost of food is
conceptualized very broadly
to include how much time
it takes for preparation,
healthy food generally
taking a lot more time
for preparation and for eating
because it's less processed.
You have to have equipment
for storage and preparation
which means you have to
have paid your utility bills
and have a refrigerator
and a stove or an oven.
It takes time and money to travel
to a full service grocery
store particularly if you live
in a low income neighborhood
where grocery stores are
not frequently located.
There are very inexpensive varieties
of fruits and vegetables
and this allows the USDA model meal plans
to often have beautifully
constructed meal plans
that will last you for a couple of days
but to get variety, for example to invest
in fruits other than an apple,
if your kids want a peach
or your kids want strawberries
or you want to have a kiwi,
those are much more expensive,
you're stuck with the lowest,
the least amount of variety.
It costs more money to
get high quality food
and then particularly in
households with children,
the fear of food waste.
So, if you can think back to an era
in which you had young kids in your house,
I might say to you as a clinician,
"get some broccoli, your kids'll love it."
The risk of buying some broccoli
and having nobody at the table eat it
and frankly, the first time
you feed your kids broccoli,
no one will love it.
The risk is high because when
that food goes in the trash,
if it's a dollar or $2
or $3 worth of broccoli
and you're feeding the whole household
on $4.90 per person per day,
that has a significant
economic implication.
Okay, so the evolution
of research on health
and food insecurity has gone very quickly
because as we recognize
that there was a problem,
there became, there was a lot of momentum
to try to understand
whether food insecurity
and health were related,
whether the problem was substantial enough
that we needed to do something about it
and then to try to figure
out what we could do
to help blunt the health
impacts of food insecurity
and so, I'm gonna start
where I started before
which is thinking about whether
food insecurity is related
to physical and mental health
and I'm gonna tell you,
this may not be extraordinarily satisfying
but I'm gonna tell you if you look
for an association between food
insecurity and any disease,
you will find it.
And part of the challenge with that
as an academic is that we
have this problem again
of which came first, the food
insecurity and the poor health
and in many cases you might
look at this and you might say,
"well, it's just much more
likely that once people are ill,
"it puts a lot of pressure
on their food budget
"and they're more likely
to become food insecure."
And so, we have spent a lot of time trying
to tease out whether it's true
that food insecurity through all
of these coping strategies
really does cause poor health
and quite recently we had I
think the first definitive study
that shows that the arrow does
in fact go in both directions.
This was actually carried
out in Canada, this study,
but I'm sure it's been replicated
to some extent in the U.S.
and the charitable food system
and the federal nutrition
system is very similar
in Canada as it is in the U.S.
Essentially what they did
is they asked households
whether they were food insecure
and in Ontario or Quebec,
in one of those provinces
I forget, I'm sorry,
they then looked in
people's medical records
for the next 11 years
to see whether they developed diabetes.
11, up to 11 years after they asked them
if they lived in a food insecure household
and you see in this red line,
the risk of developing
diabetes if you are food secure
and you see in this blue line your risk
of developing diabetes
if you are food insecure
and so, in this case, the
food insecurity came first
and you might say, "well, that's
poverty, it's low income,"
it's all the things
that go along with that
but even after adjusting for
all of these other elements,
people living in food
insecure households had more
than twice the risk of developing diabetes
and so, I'm not gonna give
you a lot more information,
I'm just gonna leave it at that
to say that food insecurity
and health are tightly related
and the problem is a big one
and I don't generally talk in cost here
because I don't think
that the reason why we address
food insecurity and hunger
in the United States is
because it's expensive,
however, cost does give
us a common language
in which to talk about food insecurity
and health in one sentence.
It gets the social service sector
and the healthcare sector aligned
and it helps us to understand
the scope of the problem.
So, I'm going to use some cost data
to try to articulate to
you how big the problem is.
In this study, done in the United States,
we use, again, a population-based survey,
so representative of everybody in the U.S.
We asked them if their
household was food secure
or food insecure and then we followed them
for the next two years for
to see every single
healthcare related expenditure
they made, every time
they went to the doctor
and how much it cost them,
every time they picked up a
prescription at the pharmacy,
every time they went
to the emergency room,
if you lived in a food insecure household,
your annual healthcare
expenditures were $1,863 more
than if you lived in a
food secure household,
if you made these populations
otherwise look totally similar, okay?
So, they have very similar health needs
but if they lived in a
food insecure household,
they had $1,863 per year more
in healthcare expenditures
and if you multiply that $1,863
by the number of food insecure
people in the United States,
you get a number that is
enormous, $77.5 billion with a B,
additional healthcare
expenditures annually associated
with food insecurity.
That's a big number and I want you to hold
that $1,863 in your head
because then you might be asking yourself,
"okay, can we do anything
to pull that number down?
"Or, if we do something
to address food insecurity
"in the U.S, does the
differential in healthcare costs
"between these two
populations get smaller?"
And I'll make you wait for that,
that's the suspense of the evening.
All right, so, can an intervention
help address the problem?
So, I'm gonna start by saying to you
that there a host of different responses
to food insecurity in the U.S.
And I didn't put a slide in here
but I'll just tell it to you,
we think of four primary responses
to food insecurity in the U.S.
The first two happen
without us even knowing it
because they happen within the household.
The first one is shifting money around
within your household budget,
this is generally what people do first
because it doesn't require anybody else
to know what's going on.
It's, "I'm not going
to pay the utility bill
"because I need to buy food.
"I'm not gonna refill my prescription
"'cause I need to buy food.
"I'm gonna wait until next month
"to buy my winter coat to buy food."
That's the first thing.
The second thing people do is call
on their own social support network.
They send their kids to
grandma's house to eat,
they ask for $100 loan
from a friend or neighbor.
Now, generally these friends and neighbors
in low income communities are also at risk
of food insecurity and hunger
but people rely on each other
and then once you exhaust those resources,
there are two other places you can go.
One is to federal nutrition
programs like SNAP
and the other is to the
charitable food system
which is our network of
food banks and food pantries
and home delivered meals and soup kitchens
which are otherwise
called free dining rooms.
I'm not gonna talk so much
about those right now,
we can talk about them in the Q and A,
I do a lot of work in that setting too
but I'm gonna talk about SNAP today
because it is by far the
largest of all of these programs
and we have a lot of administrative data
that allows us to get closer
to understanding the impact
of interventions to
address food insecurity
and how they may impact health.
So, SNAP was formerly called Food Stamps,
it was rolled out across
the United States in 1974.
It became a national program in 1974
and switched its name to SNAP
because of the stigma associated
with the term food stamps
in the last couple of decades.
In California the SNAP
program is called CalFresh.
Benefits are given to you
now not in an actual coupon
like the food stamps program
but on an electronic
benefits transfer card
that looks like a credit card
that you can take to any
SNAP authorized retailer
to use on any foods that are not prepared
and intended to be eaten
in the grocery store.
So, you can't buy a sandwich
or a rotisserie chicken
but you can buy any
other foods, not alcohol,
not toilet paper, not
baby diapers but any food.
It is one of the largest
anti-poverty programs in the U.S.
by the number of people that
it helps pull out of poverty.
In fact, SNAP and the
earned income tax credit are
the two largest anti-poverty
programs in the U.S.
The earned income tax credit,
obviously you're only eligible
for if you have earned income
and so, SNAP really is for
many populations in the U.S,
by far, because of the elimination
of many other safety net programs,
it is the primary safety
net program in the U.S. now
for many, many populations.
Importantly when we talk about SNAP
and the politics of SNAP,
this is kind of small to see
but what you see in this big blue part
of the pie here is the
percentage of the farm bill
that is dedicated,
the farm bill budget that goes
towards the federal nutrition programs.
So, it's more than 75% of the farm bill
and of that big blue piece, the
vast majority of it is SNAP.
There are a ton of other
federal nutrition programs,
the national school lunch program,
the school breakfast program,
the emergency food assistance program
that brings commodities to food banks
but SNAP is by far the greatest of these
and I highlight this
because it's really important
when we talk about changes
to the SNAP program because there is,
if you have as your goal to
reduce farm bill appropriations,
the amount of money in the farm bill,
there is basically nowhere to go except
for the federal nutrition programs
because they're such a
huge part of this pie
and because of that,
federal nutrition programs
are always a source of debate
and always under attack.
So, one of the reasons that we study SNAP
as the primary intervention
to understand food security
and how supporting food security can lead
to better health outcomes is
because it is very well
documented across decades
of work now that food insecurity very,
that SNAP very effectively
reduces food insecurity.
In fact, it pulls about 20
to 30% of households out
of food insecurity,
so it allows them to cross the threshold
from food insecurity to food security.
It's particularly effective
among households with children
but 54% of people on SNAP
are still food insecure.
So, how can that be?
There's a couple reasons, one it's
because the most food
insecure households are
the most likely to enroll in SNAP
but the benefits aren't enough
to pull these very severely
food insecure households
across the threshold to being food secure.
So, they're better off,
they're less food insecure
than they would otherwise be
but they're still not comfortable
that they have enough money for food.
Okay, so, it is very clear
that SNAP helps families
afford adequate food
and this graph just shows you what happens
to households after they enroll in SNAP
and you can see that after
six months of being on SNAP,
households are much less
likely to be food insecure,
the percent of households
in which children were
food insecure declines
rather large amount
and then the percentage of households
with very low food security
also declines a large amount.
These are the people for whom the quantity
and the quality of food has suffered
because of an inability
to make the household food budget stretch.
So, SNAP is very effective
at allowing people
to afford adequate food
so the question is,
SNAP was designed to
support food security,
everybody agrees that it does that.
Well, does it also support health?
So, here's a study that we
did about six years ago now
where we looked at every hospitalization
in the State of California
over a 10 year time period
for low blood sugar.
Now, how do people get admitted
to the hospital for low blood sugar?
It happens almost entirely
among people with diabetes
and it happens almost entirely
among people with diabetes
who have had some insult
to their system that,
some other physiologic insult,
they have a urinary tract infection,
they have have a heart attack
or something else is going wrong
and their blood sugar gets out of whack
and they end up with a
very low blood sugar.
The most severe of these low
blood sugar reactions need
to be treated in the hospital.
The vast majority of low blood
sugar reactions are treated
at home or in the clinic.
So, what we said to ourselves
from our clinical experience is we know
people are running out of money for food
at the end of the month, we
see lines at soup kitchens,
free dining rooms and food
pantries get much, much longer
at the end of the month.
We know that big box stores and
other retailers have a habit
of increasing food prices at
the beginning of the month
when SNAP benefits get
loaded onto the cards
because they know there
will be a big rush of people
with a very high demand for food.
So, we know this happens,
so what we speculated was
if you are taking your standard
diabetes medication dose
but you stopped eating as much,
you would be at higher risk
for a low blood sugar event
and if it were severe enough
to get you hospitalized,
maybe we could see this in the data.
What you see at this green
line here is your risk
of being hospitalized in
the State of California
by the day of the month,
the first, second,
third, fourth, fifth and
31st day of the month.
What you see in the red line is the risk
of hospital admission for low blood sugar
for the people who live in
the lowest income zip codes
in the state
and you see it everyday
of your month the risk
of being admitted with
low blood sugar is higher
than the general population.
This we might say is the
general impact of poverty
but what you see at the end
of the month is 27% increase
in low blood sugar
admissions for California,
in California only among the
low income population compared
to the first week of the month
and this we say is one
of the immediate health impacts
related to food insecurity
and so, this is important
because people will speculate
that none of the health impacts
of food insecurity are likely to be seen
for years or decades
and while that is true in many cases,
the development of obesity or diabetes
or heart failure will
take years or decades,
some health impacts of food insecurity
at least can be seen over
a matter of days or weeks
and so, can SNAP make a difference?
So, this is an opportunity for us
to use what we call a natural experiment
which is something that is
going on otherwise in the world
that allows us to capture
something different in the data
that we otherwise wouldn't be able to see
and in this case, the natural
experiment was the passage
of the American Recovery
and Reinvestment Act
during the Obama administration meant
to stimulate the economy and from,
in May of 2009, SNAP
benefits had a substantial
but temporary, quite dramatic
increase in benefit levels.
You can see the benefit levels here,
you have this dramatic
increase in benefit levels
and then it expired in October of 2013.
And so, we asked ourselves,
first of all can we see
this pattern of the increase
at the end of month in
low blood sugar events
in a different data set?
You always have to repeat
and if we can, does the
pattern looks the same
between in this period as it did
in this period when SNAP
benefits were higher?
And this is what we found.
We found, again, an increase in risk
of low blood sugar
events during this period
and during this period
of the American Recovery
and Reinvestment Act,
the increase in low blood sugar events
at the end of the month
disappeared, no longer there.
SNAP benefits were adequately protective
in this new population of
commercially insured adults
that we could no longer find
that end of the month increase
in low blood sugar events
and if we count up the number
of low blood sugar events
that we would have anticipated
based on what we saw here
and multiplied them by
the costs of those events,
we come to estimate that $54
million in healthcare costs
just for those blood sugar
hospitalizations were averted
because of the temporary
increase in SNAP benefits.
So, remember I said remember that $1,800
because you're gonna start wondering
to your that the $1,800
in additional healthcare expenditures
that a person living in a
food insecure household has
on average compared to someone living
in a food secure household
that $1,800 we may now ask,
"well, if you're enrolled in SNAP,
"how much does that change
that $1,800 differential?"
And you'll see here, very similar data
but looking now not whether
you're food insecure
or not food insecure
but whether you're enrolled in SNAP
or eligible for SNAP but not enrolled
and what we see here is if
you are enrolled in SNAP,
your healthcare expenditures
are about $1,400 less
than they are if you are eligible
for SNAP but not enrolled.
Now, it's a little bit
comparing apples and oranges.
So, we can't exactly say
that the $1,400 is, you know,
80% of the $1,800
and we can save 80% of
healthcare expenditures
but it gives us a good idea
that SNAP enrollment
has a substantial impact
on reducing healthcare expenditures.
So, you may ask yourself, "why is that?
"Is it all because of dietary intake?"
And although it's easy to think that,
I think there's a little,
it's a little bit more complex
and other things are going on.
This graph shows you the extent
to which people enrolled in
SNAP report different health
than people not enrolled in SNAP.
So, you can see that people enrolled
in SNAP are 10% more
likely to report they're
in excellent health,
4% more likely to report
they're in very good health
and much less likely
to report that they're
in good, fair or poor health.
The important part of this is
that people who encounter
the healthcare system
often get access to resources
that support them in enrolling in SNAP
and what that means is that a more ill
and a more frail population
tend to enroll in SNAP
and so, the question
is, "why then do people
"who are enrolled in SNAP feel
that their health is better?"
Maybe it's that SNAP is
actually doing something
to help people become healthier
and here again, I said a lot
of these health impacts
play out not over months
but mostly over years.
This is wonderful data
done by a researcher
at UC Berkeley named Hilary Hoynes
who looked at the rollout of
the SNAP program in the 1970s
and then followed children for decades
to see what happened to them
and what she saw was that children
who lived in counties
where SNAP was available,
even starting when they were in utero,
if the county had SNAP benefits available,
those children were healthier at birth,
they were less likely to
develop metabolic syndrome,
obesity, diabetes, high cholesterol.
They were more likely to
reach their educational
and academic potential,
they were more likely
to graduate from high school for example
and they were more likely
to become economically
self-sufficient as adults.
Meaning that their chances of
needing government benefits
in the future were remarkably,
were substantially less.
So, a SNAP investment
in early childhood has great impacts
on health in the long-term.
I want to just emphasize that
reaching your educational
and academic potential
and becoming economically self-sufficient
from a public health perspective is one
of the most important ways in
which we keep people healthy.
There's also been a lot of
data recently about SNAP
and other outcomes.
I offer you just a
couple of examples here.
One is on SNAP and pregnancy outcomes.
20% of SNAP recipients are
women of childbearing age,
women who are enrolled
in SNAP are less likely
to need to go to the emergency room
for a pregnancy related illness
and this is, I think, one of
the most compelling stories
of the last two years in this work.
This data shows you how much
your monthly SNAP benefit is
against the probability of needing
to visit the emergency room
for something related to your pregnancy
and what you see again is
this profound association
between your SNAP benefits and improvement
in healthcare utilization.
As your SNAP benefit increases,
your chances of needing
to go to the ER go down.
This is particularly interesting
because these households
that are getting really high
benefits, $675 per month,
these households tend
to be the most vulnerable
households, right?
The poorest households,
the households with the greatest
number of children in them
and so, we would, and therefore
probably the greatest number
of births of the mother already,
the mother's likely older,
so more likely to have
pregnancy complications.
So, by every metric, we
would expect these households
to have the highest need
for emergency room care
and yet we see them have the lowest need
for emergency room care.
Similar studies on child visits for asthma
to the emergency room,
here the mechanism is probably
by what we call cost-related
medication non-adherence
which is not taking your medications
because they're too expensive.
We know that childhood
asthma is very sensitive
to regular use of your asthma medications
and so, when people don't have access
to their medications their risk
of having an exacerbation goes up.
Again, the risk goes up
considerably depending
on your benefit level is
highly associated again
with your risk for having
an emergency room visit.
Same with visits to the emergency room
for high blood pressure
which we also think is probably related
to the cost of medications.
In fact, if we look among older adults,
if people are enrolled in SNAP,
it largely mitigates this problem.
So, again we're looking
at what's called cost-related
medication non-adherence,
not taking your medications
because it's not affordable for you.
If we look among food
insecure older adults,
people who are enrolled
in SNAP are significantly less likely
to have cost-related
medication non-adherence
than people who are eligible
for SNAP but not enrolled,
suggesting that SNAP
really helps households
to afford medications.
And a similar study to
one I showed you before
but older adults enrolled in SNAP compared
to those not enrolled in
SNAP are much less likely
to enter a nursing home.
So, they're much more likely to stay
in the community for longer.
If they are admitted to a
nursing home it's for less time,
they're much less likely to
be admitted to the hospital
and if they are admitted
it's for less time
and they're also less likely
to use the emergency room
and so, maybe it's not so surprising
that healthcare expenditures
go down with SNAP enrollment.
This study looks at what happened
in the State of Massachusetts,
again during the American
Recovery and Reinvestment Act,
so SNAP benefits went up.
What happens to Medicaid
expenditures in that state?
And you can see in the pre-ARRA period,
the healthcare expenditures
were increasing
very dramatically then
during that ARRA period,
you can see the slope
level out a little bit,
Medicaid expenditures went,
increased much less rapidly
and then as soon as the ARRA expired,
the slope of increase went
right back up to where it was.
Okay, so I hope that I have convinced you
that SNAP can help address this problem
and so then you might say to yourself,
"well, what's going on with SNAP now
"and are we going to be able
to use SNAP as one mechanism
"to invest in the health
of the population?"
And so, I'm gonna suggest,
I'm gonna give you just
a few bullet points
on four proposals within the SNAP program
and I can't tell you exactly what impact
this is gonna have on health
but I will tell you sort
of the punchline now
which is that none of these are going
to be good for the population health.
So, there's four things,
all of which you may
have been reading about
in the newspapers because
people are very interested
in these issues right now.
Categorical eligibility,
work requirements,
capping deductions for utilities
and the public charge issue.
Now, I will caveat this by saying
that these rules are
extraordinarily complex
and there is some suggestion
that they are intentionally complex
so that we can't understand them
but I'm gonna do my best to
make them as simple as possible.
It's very difficult to push against things
that are too complex for
us to even understand.
But I'm gonna give you sort
of the broad brushstrokes
and make a few generalizations
so that I don't get too wonky on you.
Although I'm happy to get wonky
if anybody wants to ask wonky
questions about these changes.
The first is called
categorical eligibility.
Categorical eligibility basically means
that if you are already,
if you are eligible for
one social service program
and those eligibility criteria
are stricter than SNAP,
then we'll just automatically
enroll you in SNAP.
You don't have to go
through a separate process
in a separate office, we'll
just say if you're already,
for example, in social,
getting social security,
we know you're eligible for SNAP anyway
so we'll just enroll you.
If you're already getting TANF, that,
TANF is what used to be called welfare,
we'll just enroll you in SNAP.
Or if you're in Medicaid,
we'll just enroll you in SNAP
because SNAP has looser
eligibility criteria
than these others
and through this mechanism
many, many people were able
to enroll in SNAP without
the bureaucratic need
to go down to a different
office, wait in line,
prove their income and prove
all of the other things
that they've just proved
at the Medicaid office.
The proposal is that these
programs would no longer be able
to link themselves and qualifying
for one program would no longer
automatically qualify you
for SNAP benefits.
The second that we've been talking
about a lot even today in the context
of the coronavirus is
about work requirements.
Now, work requirements are applicable only
to what we call ABAWDS
or able bodied adults,
what the government assumes
is somebody who's able
to work without dependents,
not taking care of children
or frail older adults
or disabled people in their household
and basically what it says is
that you can only get benefits
for three months out of
every three year period
unless you are working or
you are enrolled as a student
or you are volunteering or
you're in a job training program
and if you can't prove you're
doing any of those things,
then we won't give you any SNAP benefits.
As a matter of fact, this went into effect
in San Francisco County
on September 1st of 2018.
So, we are already subject
to work requirements
in this county.
The farm bill that was passed
in 2018 had this work
requirement proposal in it
and Congress did not approve it.
However, the USDA has found a way
to do this same thing administratively
rather than legislatively.
So, even though Congress
says "no" to this proposal,
the USDA has found a way to implement it
without Congressional approval.
We can talk about why that is afterwards
if people are interested.
Just in terms of context for today,
I will tell you that one
of the proposals to respond
to coronavirus today has
been to re-institute the,
to take away, I'll just say
to take away the work requirement rule
so that people would now
have access to SNAP benefits
on an ongoing basis.
Now, this makes me actually
want to say one other thing
in the context of coronavirus which is
that SNAP is what the
economists call counter-cyclical
which really means that it is
able to respond very quickly
to an economic downturn
and in fact it's extraordinarily
successful and why is that?
People become eligible for
SNAP when their income falls.
We very quickly get them enrolled in SNAP
and the federal government
has a very quick, streamlined
and efficient way to
push money immediately
into local communities and
that money is then spent,
it's not saved, it's spent
in local communities,
at grocery stores and
retailers immediately
and so it provides a
massive economic stimulus.
This is why programs
like the American Recovery
and Reinvestment Act happen,
it's also why people enrolling
in SNAP in the next few weeks
as coronavirus has more of
an economic impact will help
to support the economy
and it is also why legislators have tried
to pull back on all of
these proposals just
in the last couple of days
to allow SNAP to have this
counter-cyclical effect
that supports the economy.
The things you didn't realize
you were gonna learn tonight
when you were talking about health.
Utility deduction, so another
really complicated one.
Basically what you need to know
about this one is that the formula
for calculating how much benefits you need
from SNAP was developed based
on data from the 1960s
and in the 1960s the average household
in the United States spent 30%
of their entire household income on food
and so, basically the
way the calculation works
even today is you go into the SNAP office,
you tell them how much
your household income is,
they have a calculation
for how much they think you
should be spending on food
as a four person household
or a six person household
and then they say, "okay,
you put in 30% of your income
"and we'll cover the rest of the gap."
The problem is that putting
in 30% of your income
on food is an extraordinary amount of food
in today's society
and people can't realistically
put, in many cases,
30% of their household income into food.
One of the reasons, one of
the ways states have tried
to address this massive problem
that we're still using
a 1960s calculation is
by having income deductions,
one of them is utilities
and again, capping these
income deductions has been done
through regulatory efforts
not legislative effort
so even though Congress
hasn't approved these,
they have found a way to do it anyway
and I mention this because hunger
and food insecurity is
one of these few issues
that is often very bipartisan.
Republicans and Democrats
agree on feeding people
who are hungry
but we are finding a lot
of regulatory efforts
to roll this back.
Okay, public charge, I'm sure
that you guys have heard
a lot about public charge
but for those of you who
don't know the details of it,
public charge has actually been a part
of federal immigration law for decades,
it applies only to people
who are applying for a Visa
to come to the United States
or a green card that makes you
a lawful permanent resident,
not in fact to become a citizen
although there's so much
confusion around this
and I'll show you this in a minute
that it has been
misinterpreted and been allowed
to scare a huge population of people
for whom it doesn't really
probably have an impact.
So, it does not apply
to green card holders
that are applying to become U.S. citizens
and basically what the
public charge rule said is
if you are reliant on
certain government benefits
that were cash transfers, you,
it would be a ding against you
in your ability to get your green card.
And traditionally the only cash transfers
that counted were social
security, TANF, welfare
and long-term institutional care
and the new public charge
rule has changed it
so that anybody who gets
any government support,
even if they're eligible
for these programs,
would be at much, would
be much less likely
to be granted a green card
and that includes anybody who uses SNAP,
anybody who enrolls in
Medicaid or Medicare
or are section eight housing
which are housing vouchers.
Any of these things can be
used as a ding against you
and make it less likely
that you'll be able
to get a green card.
And this, the Supreme Court
just ruled this constitutional
and this went into effect
just now on February 24th.
So, who is this impacting?
Well, first of all it's impacting people
who aren't actually,
who don't actually have
a reason to be impacted.
So, these are the number
of people who have asked
to dis-enroll in federal
nutrition programs
because of the chilling effect
and these are the people who
have non-citizen family members
and so, these people might reasonably
be affected, 20% dis-enrollment.
These people are all permanent resident,
these are households
where everyone is a
permanent resident already
so it shouldn't impact it
and yet the fear around it has
caused massive dis-enrollment
and these people are all citizens
and again, 9.3% of these households
also are dis-enrolling from the programs.
So, lots of fear
and the more you've
heard about the program,
the more likely you are to dis-enroll.
So, a third of people who've learned a lot
about the public charge
issue have dis-enrolled,
15% of those have heard
a little bit about it
or 13% of those who've
heard a little bit about it
and 6% of people who've heard
nothing about public charge.
The problem is this is
disproportionately impacting
the people who have incomes below 200%
of the federal poverty line,
it's disproportionately
impacting latino households
and it's disproportionately impacting
households with children.
So, the most vulnerable of the vulnerable
and if you take these four together
and you look at them as a package,
the Urban Institute very
recently released a report
estimating the impact
about 3.7 million participants will lose
federal nutrition program benefits,
2.2 million households will
see their benefits drop
by more than $127 per month
about a million kids will
lose access to school meals
because of this categorical
eligibility change
and about a million more
people would be food insecure.
So, we have learned through
a decade of this research
that food insecurity and
health are tightly connected
and it has both short-term
and long-term implications
for your health.
We know that SNAP not only
reduces food insecurity
but also mitigates the health
impacts of food insecurity
and we can speculate that
these proposed reductions
in SNAP benefits are
likely to cause poor health
and increased healthcare expenditures
and really what that means
for the healthcare system is that a dollar
that isn't spent on SNAP
benefits is not a dollar saved
by the federal government.
Much of that dollar is just put out
through Medicaid and Medicare rather
than through the SNAP program.
And so, I would contend
that this is a really sort
of ridiculous way to be
spending our resources.
With that, I will ask if
there are any questions?
Who are the champions for
this issue in Congress?
That's a great question.
As I said, hunger issues are
often bipartisan, not always.
The champions tend to
be Democrats in general
who support a stronger social safety net
and Republicans who have
the agricultural industry
as important stakeholders
in their constituencies.
And these are the groups
that often come together
to co-sponsor many
of these anti-hunger food
insecurity reduction programs.
Yeah, so a question is
about food insecurity and self-medication.
It's a great question.
Let me start, well let me
give you two points of data.
The first is around food
insecurity and tobacco use.
One of the,
food insecure households
are much, much more likely
to have the smoker in the household
and we know that smoking takes up a lot
of the household budget
but one of the things that
we also know about smoking is
that smoking substantially
blunts your appetite
and so one of the ways that people cope
with not having enough food
in the household is to smoke
and so there is a substantial
self-medication component there.
It also makes it very challenging
to support people living
in food insecure households
to stop smoking because
it's such a powerful,
you know, it makes you less anxious
and food insecurity makes people anxious.
It makes you less hungry
and food insecure people
are really hungry.
The second thing I'll tell you
is from a global perspective.
We know from a, well, and
this is related to smoking.
We know in a global
perspective that having anyone
in the household who smokes is associated
with stunting among the
children and why is that?
It's because it takes away so much
from the household food budget.
The relationships between food insecurity
and illicit drug use,
alcohol use and tobacco use,
all of those are used as
self-medication, very clearly.
Now, I will say one other thing though
about selling SNAP benefits.
It is an uncommon, it
doesn't happen commonly
but it does happen
and one of the reasons that people talk
about it happening is because
our social service benefits
in this country no
longer, for the most part,
include any cash
and so there is no way for a household
that's only getting benefits
which might be a section
eight housing voucher,
it may be a childcare voucher,
it may be SNAP benefits,
when you piece all eligible,
all of these programs together,
households still have no cash.
There's a wonderful book
published in the last couple
of years called, "America on $2 a Day."
And $2 a day is the dollar value
by which internationally we say
that people are living in extreme poverty
and yet, even in the United States,
there are many, many, many people
who have less than $2 a day in cash.
And so, that's really
generally the motivator
for selling your SNAP
benefits to get a little cash.
You know, when we think of all
of these different programs available
to low income populations in isolation,
we think of sort of
their individual capacity
to make a difference on health.
The truth of the matter is,
how can we support food security
in households in the U.S?
Well, we can give people
money for food through SNAP
but there's also really good evidence
that no matter how you
get additional money
into a low income household,
it supports food security.
So, Medicaid expansion
supports food security
'cause you can divert money
from your healthcare
budget to your food budget.
Section eight housing vouchers
reduce food insecurity
'cause you divert money
from housing to food.
Any way that, you know,
increases in minimum wage,
according to some economists,
controversial again,
reduces food insecurity
because you have more
household income coming in.
It doesn't really matter
at the household level how
you bring that money in
and when we're talking about trade-offs
between SNAP and Medicaid,
those same principles come into effect.
There are some very good
articles now showing that states
that expanded Medicaid had
lower food insecurity rates
than would have been predicted compared
to states that did not expand Medicaid.
So, with that thank you guys
for braving the pandemic
to come here for those of you in the room
and to those of you online,
thank you for sticking with us,
you're welcome.
(audience claps)
(gentle music)
