Hunger pains? SNAP timing and emergency room visits

Investigating the Poverty-Reducing Effects of SNAP on Non-nutritional Family Outcomes: A Scoping Review

INTRODUCTION/PURPOSE

Poverty-reduction efforts that seek to support households with children and enable healthy family functioning are vital to produce positive economic, health, developmental, and upward mobility outcomes. The Supplemental Nutrition Assistance Program (SNAP) is an effective poverty-reduction policy for individuals and families. This study investigated the non-nutritional effects that families experience when receiving SNAP benefits.

METHODS

We conducted a scoping review using the PRISMA Guidelines and strategic search terms across seven databases from 01 January 2008 to 01 February 2023 (n=2456). Data extraction involved two researchers performing title-abstract reviews. Full-text articles were assessed for eligibility (n=103). Forty articles were included for data retrieval.

RESULTS

SNAP positively impacts family health across the five categories of the Family Stress Model (Healthcare utilization for children and parents, Familial allocation of resources, Impact on child development and behavior, Mental health, and Abuse or neglect).

DISCUSSION/CONCLUSION

SNAP is a highly effective program with growing evidence that it positively impacts family health and alleviates poverty. Four priority policy actions are discussed to overcome the unintentional barriers for SNAP: distributing benefits more than once a month; increasing SNAP benefits for recipients; softening the abrupt end of benefits when wages increase; and coordinating SNAP eligibility and enrollment with other programs.

SNAP Participation and Emergency Department Use

OBJECTIVES

To examine whether Supplemental Nutrition Assistance Program (SNAP) participation is associated with emergency department use among low-income children and whether any such association is mediated by household food hardship and child health status and/or moderated by special health care needs (SHCN) status. We hypothesized SNAP to be associated with reduced likelihoods of emergency department use, with greater effect sizes for children with SHCN and mediation by food hardship and health status.

METHODS

In this secondary analysis, we estimated a bivariate probit model (with state-level SNAP administrative policies as instruments) within a structural equation modeling framework using pooled cross-sectional samples of children in low-income households from the 2016 to 2019 iterations of the National Survey of Children's Health (n = 24 990).

RESULTS

Among children with and without SHCN, respectively, SNAP was associated with: 22.0 percentage points (pp) (95% confidence interval [CI] 12.2-31.8pp) and 17.1pp (95% CI 7.2-27.0pp) reductions in the likelihood of household food hardship exposure (4.8pp difference-in-differences, 95% CI 2.3-7.4pp), 9.7pp (95% CI 3.9-15.5pp) and 7.9pp (95% CI 2.2-13.6) increases in the likelihood of excellent health status (1.9pp difference-in-differences, 95% CI 0.7-3.0pp), and 7.7pp (95% CI 2.9-12.5pp) and 4.3pp (95% CI 1.0-7.6pp) reductions in the likelihood of emergency department use (3.4pp difference-in-differences, 95% CI 1.8-5.1pp).

CONCLUSIONS

We found SNAP participation was associated with lower likelihoods of emergency department use, that better food hardship and health statuses mediated this association, and that effect sizes were larger among children with SHCN. Food hardship relief may improve outcomes for vulnerable children and the health systems serving them.

Pain-driven emergency department visits and food insecurity: a cross-sectional study linking Canadian survey and health administrative data

BACKGROUND

As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals' pain-driven emergency department visits.

METHODS

We designed a cross-sectional study linking the Canadian Community Health Survey 2005-2017 to the National Ambulatory Care Reporting System 2003-2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chest-throat pain, abdomen-pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non-pain-driven emergency department visits in the models.

RESULTS

The sample contained 212 300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [CI] 1.20-1.68), 1.64 (95% CI 1.37-1.96) and 1.99 (95% CI 1.61-2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents. Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits.

INTERPRETATION

Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization.

Food insecurity during the COVID-19 pandemic: evidence from a survey of low-income Americans

The COVID-19 pandemic significantly increased food insecurity despite emergency legislation that put more resources into food assistance programs, increased unemployment benefits, and provided stimulus payments. We conducted a survey in the US on food insecurity among low-income Americans during the early months of the pandemic. While we cannot estimate causal effects, we are able to show important associations between food insecurity and nutritional and economic assistance that highlight the need to ensure that those newly at risk for food insecurity are able to connect to resources. For example, our results indicate that those who lost jobs due to the pandemic reported the highest level of food insecurity and also the lowest engagement with food assistance programs. The SNAP expansion appears to be important only among groups with higher levels of income stability including non-minority households and those not experiencing a job loss. Thus, the SNAP expansion may not have had a meaningful impact on those most at risk for food insecurity. Finally, our data highlight the importance of school meal programs during normal times. Those who took advantage of school meals before the outbreak are more likely to have experienced food insecurity during the pandemic-related school closures.

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

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

SNAP timing and food insecurity

This paper makes several contributions to the literature regarding the measurement of food insecurity and implications for estimating factors that affect this outcome. First, we show that receipt of benefits from the Supplemental Nutrition Assistance Program (SNAP) has a systematic effect on responses to questions in the 12-month food security module (FSM). We find that the probability of affirming more severe food hardships items, and the probability of being classified as having very low food security (VLFS), is higher just before and just after households receive their benefits. This leads to an under-estimate of VLFS by 3.2 percentage points for the SNAP sample (about 17 percent of prevalence). We also provide informative bounds on the relationship between SNAP and VLFS and show that the treatment effect of SNAP on VLFS is also likely underestimated.

Mostly harmless regulation? Electronic cigarettes, public policy, and consumer welfare

Electronic cigarettes are a less harmful alternative to combustible cigarettes. We analyze data on e-cigarette choices in an online experimental market. Our data and mixed logit model capture two sources of consumer optimization errors: overestimates of the relative risks of e-cigarettes and present bias. Our novel data and policy analysis make three contributions. First, our predictions about e-cigarette use under counterfactual policy scenarios provide new information about current regulatory tradeoffs. Second, we provide empirical evidence about the role consumer optimization errors play in tobacco product choices. Third, we contribute to behavioral welfare analysis of policies that address individual optimization errors. Compared with standard cost-benefit analysis, our behavioral welfare economics analysis leads to much larger estimates of the costs of policies that discourage e-cigarette use or the benefits of policies that encourage e-cigarette use.

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

OBJECTIVE

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

DESIGN

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

SETTING

Minneapolis-St. Paul, Minnesota, metropolitan area.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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