SNAP and the Farm Bill: Food Insecurity as a public health issue

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{***Noah***}

Coming up on a special collaborative episode of Harvard Chan: This Week in Health and Review of Systems…

The future of SNAP: America’s largest nutritional safety net.

{***Sara Bleich Soundbite***}
(It also lifts families out of poverty. And that’s because it’s providing income to families in the form of food benefits. And so, for example, in 2014, 4.7 million families were lifted out of poverty, and in 2016 it was about 3.6 million families.)

In this episode: How the political wrangling over the Farm Bill could have important implications for health in America.

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{***Audrey***}

Hey listeners – this week, something a little different! Harvard Chan: This Week in Health, the weekly podcast from the Harvard T.H. Chan school of public health and Review of Systems, the weekly podcast from the HMS Center for Primary care have teamed up to do a show together!

{***Noah***}

We’re talking about food stamps, or SNAP, and how upcoming legislation in the Farm Bill will shape SNAP policy over the next five years.

{***Audrey***}

Changes in SNAP policy will have important public health implications and affect the food insecure patients we see in our clinics in primary care – so it’s a perfect topic for us to examine together.

{***Noah***}

I’m Noah Leavitt, host of Harvard Chan This Week in Health.

{***Audrey***}
I’m Audrey Provenzano, a PCP and host of Review of Systems.

{***Noah***}

We have two guests joining us this week: Sara Bleich, who is a Professor of Public Health Policy at the Harvard Chan School in the Department of Health Policy and Management. She is also the Carol K. Pforzheimer Professor at the Radcliffe Institute for Advanced Study and is an expert in obesity and food policy.

{***Audrey***}

We’re also speaking via Skype with Hilary Seligman, who is a primary care physician and Associate Professor of Medicine and of Epidemiology and Biostatistics, UCSF. She is also a Senior Medical Advisor for Feeding America, Director of CDC’s Nutrition and Obesity Policy Research and Evaluation Network and the founder of EatSF: A Healthy Food Voucher Program for Low-Income Residents of San Francisco.

{***Noah***}

You can find more information about both of our guests on our websites, for Review of Systems go to www.hms.primarycare.edu and click on podcast at the top of the page, and for This Week in Health go to hsph.me/thisweekinhealth.

But now, let’s dive into our conversation with Sara and Hilary.

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PROVENZANO: So thank you both so much for joining us. I thought maybe we’d start with setting the table a little bit for our conversation. And start with some general questions. What is the Farm Bill? What does it have to do with SNAP, which is more commonly known as food stamps? We can start with Sara.

SARA BLEICH: Sure. So the Farm Bill is a very large multi-year bill that governs all of federal agriculture and food programs. And it’s typically reauthorized every five years by Congress and includes multiple titles.

And in the 2014 Farm Bill, for example, there were 12 titles, of which the Nutrition Bill, which is where SNAP sits, or formerly food stamps, was about 80%. The total cost of the 2014 Farm Bill was about $489 billion over five years. And again, about 80% of that was for SNAP, which is the food stamp program.

Now, the current Farm Bill, which is the 2014 Farm Bill, will expire on September 30, which is what makes this conversation really relevant. And just a few words about SNAP. It is by far the largest of the federal nutrition assistance programs in the US. It has an annual budget of about $71 billion. And on a monthly basis, helps more than 40 million low income Americans afford food each month, half of whom are children.

And there are very few restrictions within the SNAP program of what can be purchased. And in terms of the actual amount that people receive on a per person basis, it equates to about $1.40 per person per meal.

NOAH LEAVITT: And so Hilary, you’ve published dozens of pioneering studies which look at the relationship between health outcomes and access to food. So can you explain a little bit about what we know about what happens to people’s health when they suffer from food insecurity, or when they have insufficient access to food?

HILARY SELIGMAN: Yes. These relationships are actually very complex. But you can think of it two ways. One is that when people have the experience of inadequate access to food that’s sustained over a long period of time, which is a frequent pattern of food insecurity in the US, they are at higher risk of developing disease. And once they have disease, it makes it much more difficult to manage those diseases. And we see that across a bunch of different health outcomes.

We also know, though, that it’s really expensive to be unhealthy in the United States. There’s all kinds of out-of-pocket health care expenditures no matter how good your health insurance coverage is. And it’s also really hard when you’re chronically ill to maintain employment.

So it is both true that food insecurity is associated with the risk of a lot of chronic diseases, especially diet sensitive chronic diseases, but also that being chronically ill puts people at higher risk of being food insecure.

NOAH LEAVITT: Is it the case where food insecurity, like you’re saying, will kind of exacerbate an existing chronic disease?

HILARY SELIGMAN: Yeah, so let’s just take an example of diabetes. If you have diabetes, then your medical team is going to focus on two very key and equally important treatments. The first is medications, and the second is diet. Diet is absolutely critical to diabetes management.

And when you don’t have enough money in your food budget to afford diabetes appropriate foods, which are much more expensive overall, particularly calorie for calorie, than a regular diet, then it’s much more challenging to get your diabetes under control. And when people aren’t able to keep their diabetes under control, they are at higher risk of complications, like amputations and blindness.

And these are things that have huge issues for quality of life. They also have huge implications across the health system as a whole in terms of how much money they cost.

AUDREY PROVENZANO: Generally, what effect is seen when people get access to SNAP or food stamps? Does access to SNAP improve health outcomes?

HILARY SELIGMAN: The answer is absolutely. We have a ton of evidence of this across many different dimensions. The first is to state that we know absolutely without a doubt that SNAP reduces rates of food insecurity. And the best estimates are that it reduces food insecurity by 20% to 30%, particularly high rates in households with children.

And once people are less food insecure, a number of things can happen that predispose people to better health. The first is they can afford better food. The second is they have to make fewer everyday choices between food and other things that are important for their health.

So for example, do I buy food, or do I refill my medication? Do I buy food, or do I pay the co-payment to go see my doctor?

SARA BLEICH: Yeah. So to add to that, we started off by saying that SNAP is a very modest benefit. So it averages out to $1.40 per person per meal. Those are the levels in 2017.

But as you just heard from Hilary, it actually has a lot to improve health and well-being. And so in addition to sort addressing food insecurity and helping more American families no longer be food insecure, it also lifts families out of poverty. And that’s because it’s providing income to families in the form of a food benefit.

And so, for example, in 2014, 4.7 million families were lifted out of poverty. And in 2016, it was about 3.6 million families.

And in terms of other specific health benefits, SNAP is associated with moms having fewer children at low birth weight. This is particularly true for black moms and moms living in high poverty areas.

And it’s also associated with long-term health. And so, for example, people on SNAP are more likely to report excellent or very good health, as compared to low income participants who are not enrolled in the program.

NOAH LEAVITT: So do we see that people, I guess, maybe go in and out of SNAP usage? So they might be on SNAP for a period, maybe things improve. They don’t need benefits. I mean, is that what we typically see? Or we typically see people be on SNAP for long periods of time, decades?

SARA BLEICH: Yeah, so the answer is it depends. It’s definitely for some families very cyclical where they come in and out of the program as their income changes. And then there are families who are on it for a very short period of time and never on it again.

And a really good example of that is with the 2008 recession where the roles of SNAP, meaning the number of people enrolled in the program, increased to record high numbers because there were families that for the first time were in an income position where they simply could not afford food. And for the first time they become eligible for the program.

And so though the high watermark during that time was about 44 million Americans enrolled on a monthly basis. Now that number is about 41.

NOAH LEAVITT: And so kind of a multi-part question looking at the current state of the Farm Bill as it moves through Congress, I guess the first part of that is, what types of changes has the Trump administration tried to make to SNAP?

And then as this kind of works through Congress, it seems like we’re starting to see some differences between the House and Senate bills. So can you kind of articulate those a little bit?

SARA BLEICH: Yep. So in terms of what President Trump and the Trump administration have tried to do with the program, in their 2019 budget bill, they tried to make a significant amount of cuts to the program. So about over $200 billion over 10 years.

One of the main ways that they wanted to make that cut was something that became quite a contentious issue, which was effectively creating what they called America’s Harvest box. And that would give participants in the program about half of their benefits in the form of boxes that were shipped to them from the government with shelf stable items in them.

And the reason that was so controversial was, one, because currently if you have SNAP benefits, it effectively works like a credit card. You can use it at the supermarket. There are over a quarter of a million SNAP authorized retailers around the country. And you can buy pretty much anything except for prepared food, like a rotisserie chicken or things like toilet paper or cigarettes. And so this will take a lot of the choice out of the program. It is highly unlikely that it will happen, but it was proposed by the Trump administration.

Now, in terms of where the bill is right now, so, again, it will expire on September 30. In the middle of May, the House took a vote, and it failed.

And to your point about some of the main distinctions, one key issue, which is not an agreement between the House and the Senate, is the issue of work requirements. This is something that has been brought up in SNAP. It has also been brought up in Medicaid.

So the Trump administration thinking about this work requirements across different social safety net programs. And effectively, it would require adults in the program who are able-bodied to spend 20 hours per week working or in state-run training programs. And the Democrats are very strongly against that.

Another thing that held up the vote on the House bill was that the House Freedom Caucus sort of said we’re not going to vote on this unless we vote on immigration issues. And so they effectively held the Farm Bill hostage, you could think of it in that way. And so the vote didn’t happen.

And so fast forward to mid-June, and the Senate passed their own bipartisan version of the Farm Bill. And now, the Senate is currently– it’s expected this week that the bill will go to the larger Senate. It was in Senate Ag, the Senate Agricultural Committee. It will go to the larger Senate for them to think about it.

And then from there, the House has to come up with their bill. And they have to bring those two things together. So it remains to be seen.

I think the challenge for listeners to think about is, again, with the bill expiring on September 30, there is a lot of steps that have to happen. And so I suspect later in this podcast we’ll talk about what would happen to SNAP if the bill is not passed by September 30.

AUDREY PROVENZANO: So there’s been an increasing movement among hunger advocates built on the growing evidence that access to healthy foods can improve health outcomes as Hilary Seligman’s research has shown. And also some evidence that it can decrease health care costs as you mentioned earlier, Hilary, is this idea of food as medicine or food as medicine.

And there’s now a working group of the Hunger Caucus in the House of Representatives spearheaded by Congressman Jim McGovern called Food is Medicine. And so we wanted to know, do you think that this group will have any effect on the forthcoming legislation? Maybe we can start with Hilary and then go to Sara.

HILARY SELIGMAN: The best way to think about this, I think, is to understand the implications of the concept of Food is Medicine on long-term health outcomes and health costs. If you understand food as being a really critical part of the population staying healthy and you see the possibility of the population being healthier as a way to save money in the health care budget, that is potentially a way that this Food is Medicine conversation may add support to a group that is interested in maintaining SNAP benefits.

So do I think that this group will have an effect on forthcoming legislation? I think the pressure right now is really behind finding strategies to get people off of SNAP. And this is a counterbalance. This Food is Medicine movement is a counterbalance, a really important counterbalance. But there are all kinds of pressures out there that I think are really strong. And it’s going to make this effort to expand SNAP benefits really challenging.

SARA BLEICH: And what I would add to that is historically the SNAP program, formerly food stamps, was designed to address hunger in America. And it also had the dual purpose of lifting families out of poverty. It’s really only been more recently that it has had an expressed focus on nutrition. And part of what Food is Medicine, that movement, is doing is it’s picking up on the parts of SNAP which are focused more on nutrition.

Now, the challenge, I think, of having that movement have a meaningful impact on the Farm Bill is that there is a very strong anti-hunger contingency which have proven to be incredibly good advocates for the SNAP program. But that same anti-hunger contingency is very reliant on philanthropic dollars from different corporations in the US.

And my sense is that what that has meant is that there has been a very clear focus on the hunger piece, or the food insecurity as we think about it now, and less of a focus on the nutrition piece because it’s much more controversial. And my read of the anti-hunger community is that the largest groups fall more in the ending hunger side, as opposed to increasing nutrition side. And those can sometimes be at odds with each other. So I’m somewhat pessimistic about the ability of the Food is Medicine group to have a very strong voice in the 2018 Farm Bill.

That said, I think there are a number of advocacy organizations that are trying to think about how do we incorporate more nutrition in a meaningful way in the program, in large part because if the diets of participants are poor, that has ripple effects that may affect other safety net programs. And that’s something the government should be thinking about.

NOAH LEAVITT: Just a quick follow-up there, for either Hilary or Sara, I mean, that kind of balance of just providing food versus increasing the nutritional quality, I mean, is that something that is feasible given current funding for SNAP? What would need to change, I guess, to strike that balance? Would it be an increase in funding? I mean, is there a way to get to that balance?

SARA BLEICH: So the current SNAP benefit, and this I think is pretty widely agreed upon by expert, the current SNAP benefit is not adequate. And yes, it lifts families out of poverty. Yes, it reduces food insecurity. But it’s very small. And there have been a number of reports which sort of show that the amount needs to increase.

So one way to answer your question is at the current amount, are there ways to meaningfully increase nutrition without making people more food insecure? And I think the answer to that is probably yes. A better scenario would be if the actual size of the benefit increases. And by doing so, you give people more flexibility to purchase foods that tend to be healthier and also tend to be more expensive. So you can think about that as buying fresh fruits and vegetables is typically more expensive than buying shelf stable items.

And it also maybe that for some families making those purchases is less desirable because they’re not sure their kids are going to eat them. And so there are all sorts of trade-offs I think that families are making.

I think the big picture way to think about it is there are a lot of groups that care a lot about the fate of SNAP participants. And I think everyone has the right intentions in mind. I think what has happened is that the program, meaning SNAP, needs to be modernized in ways that make it very consistent with the current disease burden in the country, which is largely related to diet related diseases.

And also make sure that SNAP does not become in jeopardy of congressmen and congresswomen pointing to it and saying, is the program causing poor diet? Is the program leading to obesity? Are there things we should be doing to change it? And sort of jeopardizing the program largely.

HILARY SELIGMAN: I agree with absolutely everything that Sara said. I also want to add to this that it is absolutely true that the diets of SNAP recipients are really, really poor. It is also true that the diets of all Americans is really, really poor.

And the small degree to which the diet of a SNAP participant is poorer than that of the rest of the United States is probably largely attributable to what Sara just said really precisely, which is that although most people in SNAP are less food insecure than they would be if they weren’t in SNAP, they still don’t have enough money to afford healthy foods because benefits are inadequate.

And so when we think about poor diets, we really need to be thinking about the problem of super adequate access to really poor nutritional items in the entire food system for everybody in America. And we don’t want the focus on the diet of SNAP recipients to make people think that the diets have SNAP recipients are really very much different than anybody else in the United States. That’s one challenge with focusing our efforts on improving dietary intake in the United States on the SNAP population.

NOAH LEAVITT: And so Hilary, to you again, Sara spoke a couple of minutes ago about some of the changes being proposed to SNAP, including this idea of the work requirements. How do you see how these changes, especially work requirements, may actually affect the health of SNAP recipients if they actually end up in the final version of the Farm Bill?

HILARY SELIGMAN: Yeah, a couple of things. The first thing to mention is to remember that almost 2/3 of SNAP recipients are children, disabled, or the elderly. So when we’re talking about work requirements, we’re actually talking about a very small piece of the SNAP pie.

The other thing to think about goes back to a conversation that we had earlier in the podcast. There are two reasons that people come off of SNAP. The first, and the best reason, is they don’t need it anymore. Their incomes have gone up. And they can now afford adequate food with the resources available within their household.

The second reason people come off of Snap is they do need it, but the administration issues or the bureaucratic issues involved in enrolling or the stigma involved enrolling and re-enrolling becomes overwhelming. And that actually is an enormous reason why people come off of SNAP.

And that’s one of the things that we worry about with work restrictions is that people who need SNAP benefits and who otherwise would qualify for SNAP benefits are going to give up and say this is not even worth the trouble because there are so many bureaucratic and administrative things to do.

So what happens then when you restrict access to SNAP overall? Well, we know SNAP is associated with better health. And we know SNAP is associated with lower health care costs.

And so if we extrapolate from that well-understood data, we speculate that when SNAP goes away, we will see increased food insecurity rates, poorer health, and larger health care costs, which really means that we are just pushing the cost of food insecurity in this country into our health care budget, rather than into our nutrition budget, which is largely what we’re negotiating in the Farm Bill.

SARA BLEICH: And I would just add to that the vast majority of people in SNAP that can work do work. And so one push-back from states, because work requirements have existed in SNAP previously, is that it’s a huge administrative burden for states to actually do this because it doesn’t apply to that many people on the program.

And so I think as this work requirement piece plays out, there’s the SNAP participant side of it. It makes it more burdensome to be in the program. But there’s a state administrative side of it, which is, is this a viable use of resources because, again, the vast majority of people in the program that can work already do so.

NOAH LEAVITT: Just a quick follow-up because the point Hilary made about kind of the stigma surrounding SNAP. I mean, is there research on whether it’s SNAP or kind of other social safety nets? I mean, do we know about how that stigma may also affect health, whether it’s on SNAP or kind of other safety net programs?

HILARY SELIGMAN: There’s been lots of research here. And actually, the impetus behind the change in the program from food stamps to the Supplemental Nutrition Assistance Program was a desire to try to reduce some of that stigma. There is still, though, a very persistent stigma around receipt of benefits in many populations. And we know that this keeps people from enrolling, particularly in many cases older adults from enrolling. And enrolling in a program that, again, we think has really substantial benefits. And so addressing that stigma is a challenge.

We also know that any time we talk about SNAP in a language of let’s restrict the dietary intake or the dietary choices of people getting SNAP. Let’s make sure that people on SNAP are working. Let’s try to do all of these things to make sure that people on SNAP have good behavior. That’s the tone of a lot of these conversations. And we know that even just those conversations add substantially to the stigma associated with enrolling in the program.

And again, we think that has really important long-term costs, not only for individuals and households and communities, but for the country overall.

AUDREY PROVENZANO: Yeah, I think there’s a strong sense of a desire to identify deserving and undeserving poor in a lot of these programs– SNAP and Medicaid. And not sure if it’s necessarily uniquely American, but it’s a theme that plays out in a lot of programs that serve the poor in the United States.

HILARY SELIGMAN: Of course, and what we understand through the data and through these conversations is that the concept of deserving and undeserving is a funny way to frame it because it is very clear from this data that these populations are worthy of our investment. Because we get a lot down the line from ensuring that people remain food secure.

So let me just give you an example. Food secure children are more likely to achieve their academic potential. They’re more likely to graduate from high school. They’re more likely to have the long-term capacity to maintain steady employment at a livable wage if we invest in food security while they are younger.

So these investments pay off over and over down the line. We just have to be willing to make them early.

AUDREY PROVENZANO: What should listeners look for in the news in the coming weeks and months? As you mentioned, that the bill expires in September, so really the clock is running. And the legislation must be passed and signed by the fall, or what will happen to SNAP beneficiaries?

SARA BLEICH: So there’s, as I’m sure your listeners are well aware, there’s a lot going on right now in the news. There are a lot of competing priorities. And so it will be interesting to see how this issue plays out. And if we see more of the Farm Bill being held up because of votes on other issues, like we saw with the House attempt and the immigration bill.

So big picture, the point to keep in mind is that enacting full legislation for a 2018 Farm Bill is going to be difficult. And that’s especially true because we have upcoming midterm elections. And particularly, that could have the effect of slowing things down.

It could also have the effect of creating a sense of urgency on the side of House Republicans who potentially may lose a number of seats and have a lower majority, or may lose their majority in the House. And so that may actually make things move a little bit faster. It remains to be seen.

It’s expected this week that the full Senate is going to debate the Farm Bill that passed in mid-June from the Senate Ag Committee. And then after that, the expectation is that the House will reconsider their Farm Bill. This could happen as soon as this week.

And the caveat is that will likely happen if Republican leaders choose to vote on a pair of immigration bills. And so we’ll see if that actually happens.

Now, what happens if we get to September 30 and there is no bill? Now, for the SNAP program, it does have mandatory permanent funding, which means it will continue on as is. The challenge is that there are a number of innovative programs that are included in the 2014 Farm Bill that will not continue.

And one example of that are what’s called FINI grants. That stands for Food Insecurity and Nutrition Incentive grants. There was $100 million included in the 2014 Farm Bill. And the idea of those is to go to farmers’ markets and look for interesting financial incentives that will encourage fruit and vegetable purchases amongst SNAP participants.

And it’s that sort of research, which potentially has the ability to increase the nutrition profile of people participating in the program. And it’s those sorts of things that would no longer exist if there isn’t a new Farm Bill that happens on or around September 30.

And so it could be that we’ll see a short-term extension. It could be that we’ll see a long-term extension. But I think that it’s very, very hard to predict right now. We’re only in June. And there’s a lot of politics to happen between now and September. So it could happen very quickly, or it could happen very slowly.

HILARY SELIGMAN: What I would add is just that it’s a really critical time period for SNAP. And the amount of press that this program has gotten over the last six months, or even the last year, is really important, I think, for communicating how important this program is to the health of the US.

And I would hope that this debate is really illustrating to people how important this program is and how much investing in SNAP benefits is really going to contribute long-term to keeping the United States healthy and at its peak.

{***Audrey***}
You’ve been listening to a very special episode of Review of Systems the podcast from the HMS Center for primary care, and This Week in Health, the podcast from the Harvard T.H. Chan School of Public Health.

Once again, I’m Audrey Provenzano.

{***Noah***}

And I’m Noah Leavitt.

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{***Audrey***}

We’d love to hear feedback and suggestions, so you can tweet at us @RoSpodcast or @HMSPrimaryCare or @HarvardChanSPH

Thanks for listening!