Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study

Abstract

BackgroundThe Supplemental Nutrition Assistance Program (SNAP) provides approximately US$70 billion annually to support food purchases by low-income households, supporting approximately 1 in 7 Americans. In the 2018 Farm Bill, potential SNAP revisions to improve diets and health could include financial incentives, disincentives, or restrictions for certain foods. However, the overall and comparative impacts on health outcomes and costs are not established. We aimed to estimate the health impact, program and healthcare costs, and cost-effectiveness of food incentives, disincentives, or restrictions in SNAP.Methods and findingsWe used a validated microsimulation model (CVD-PREDICT), populated with national data on adult SNAP participants from the National Health and Nutrition Examination Survey (NHANES) 2009–2014, policy effects from SNAP pilots and food pricing meta-analyses, diet–disease effects from meta-analyses, and policy, food, and healthcare costs from published literature to estimate the overall and comparative impacts of 3 dietary policy interventions: (1) a 30% incentive for fruits and vegetables (F&V), (2) a 30% F&V incentive with a restriction of sugar-sweetened beverages (SSBs), and (3) a broader incentive/disincentive program for multiple foods that also preserves choice (SNAP-plus), combining 30% incentives for F&V, nuts, whole grains, fish, and plant-based oils and 30% disincentives for SSBs, junk food, and processed meats. Among approximately 14.5 million adults on SNAP at baseline with mean age 52 years, our simulation estimates that the F&V incentive over 5 years would prevent 38,782 cardiovascular disease (CVD) events, gain 18,928 quality-adjusted life years (QALYs), and save $1.21 billion in healthcare costs. Adding SSB restriction increased gains to 93,933 CVD events prevented, 45,864 QALYs gained, and $4.33 billion saved. For SNAP-plus, corresponding gains were 116,875 CVD events prevented, 56,056 QALYs gained, and $5.28 billion saved. Over a lifetime, the F&V incentive would prevent approximately 303,900 CVD events, gain 649,000 QALYs, and save $6.77 billion in healthcare costs. Adding SSB restriction increased gains to approximately 797,900 CVD events prevented, 2.11 million QALYs gained, and $39.16 billion in healthcare costs saved. For SNAP-plus, corresponding gains were approximately 940,000 CVD events prevented, 2.47 million QALYs gained, and $41.93 billion saved. From a societal perspective (including programmatic costs but excluding food subsidy costs as an intra-societal transfer), all 3 scenarios were cost-saving. From a government affordability perspective (i.e., incorporating food subsidy costs, including for children and young adults for whom no health gains were modeled), the F&V incentive was of low cost-effectiveness at 5 years (incremental cost-effectiveness ratio: $548,053/QALY) but achieved cost-effectiveness ($66,525/QALY) over a lifetime. Adding SSB restriction, the intervention was cost-effective at 10 years ($68,857/QALY) and very cost-effective at 20 years ($26,435/QA...

Food insecurity screening: A missing piece in cancer management

“…71 Many food assistance programs have restricted service hours, documentation requirements, and a limited quantity and choice of food. 74,75 Therefore, several different opportunities exist within cancer clinical care with which to better support food-insecure patients: 1) including food among the list of "practical" sources of cancer distress in the NCCN DT; 67 2) creating systems for food insecurity screening using the HVS; 3) connecting food-insecure patients with support for accessing community-based resources for food or federal nutrition programs; and 4) ensuring that patients are enrolled in all other budget-relieving benefits for which they are eligible, including copayment assistance. For example, Gany et al and the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center implemented a model of hospital-based food pantries at 5 cancer clinics in New York City.…”

“…73 In addition, as the medical community increasingly recognizes the detrimental effects of food insecurity on individual health, health care use, and societal costs, Medicare, Medicaid, and other insurers are exploring opportunities to allow health care providers to prescribe healthy foods using various implementation models. 74,75 Therefore, several different opportunities exist within cancer clinical care with which to better support food-insecure patients: 1) including food among the list of "practical" sources of cancer distress in the NCCN DT; 67 2) creating systems for food insecurity screening using the HVS; 3) connecting food-insecure patients with support for accessing community-based resources for food or federal nutrition programs; and 4) ensuring that patients are enrolled in all other budget-relieving benefits for which they are eligible, including copayment assistance.…”

Legal Feasibility of US Government Policies to Reduce Cancer Risk by Reducing Intake of Processed Meat

“…There already is no processed meat in food packages under the Special Supplemental Nutrition Program for Women, Infants, and Children, known as WIC. Although no current policies target processed meats in the much larger Supplemental Nutrition Assistance Program (SNAP), a simulation analysis estimated that a combined program to incentivize purchases of healthier foods and disincentivize other foods (including processed meats) would prevent nearly 1 million cardiovascular events and save more than $60 billion in health care and other government costs over a lifetime of current SNAP participants . The government also could reduce processed meat sales in federally operated cafeterias through changes to the Food Service Guidelines for Federal Facilities or food standards at the Department of Veterans Affairs (for veterans) and Department of Defense (for active duty military).…”

Availability of Grocery Delivery to Food Deserts in States Participating in the Online Purchase Pilot

“…6 Delivery might extend these benefits in areas of highest need. Future studies should evaluate how best to leverage and finance online grocery purchasing and delivery to enhance dietary quality, especially among SNAP recipients.…”