State-Level and County-Level Estimates of Health Care Costs Associated with Food Insecurity.

IntroductionFood insecurity, or uncertain access to food because of limited financial resources, is associated with higher health care expenditures. However, both food insecurity prevalence and health care spending vary widely in the United States. To inform public policy, we estimated state-level and county-level health care expenditures associated with food insecurity.MethodsWe used linked 2011-2013 National Health Interview Survey/Medical Expenditure Panel Survey data (NHIS/MEPS) data to estimate average health care costs associated with food insecurity, Map the Meal Gap data to estimate state-level and county-level food insecurity prevalence (current though 2016), and Dartmouth Atlas of Health Care data to account for local variation in health care prices and intensity of use. We used targeted maximum likelihood estimation to estimate health care costs associated with food insecurity, separately for adults and children, adjusting for sociodemographic characteristics.ResultsAmong NHIS/MEPS participants, 10,054 adults and 3,871 children met inclusion criteria. Model estimates indicated that food insecure adults had annual health care expenditures that were $1,834 (95$1,073-2,595, P < .001) higher than food secure adults. For children, estimates were 80 higher, but this finding was not significant (95% CI, -$171 to$329, P = .53). The median annual health care cost associated with food insecurity was $687,041,000 (25th percentile,$239,675,000; 75th percentile, $1,140,291,000). The median annual county-level health care cost associated with food insecurity was$4,433,000 (25th percentile, $1,774,000; 75th percentile,$11,267,000). Cost variability was related primarily to food insecurity prevalence.ConclusionsHealth care expenditures associated with food insecurity vary substantially across states and counties. Food insecurity policies may be important mechanisms to contain health care expenditures

Cost of living, Healthy Food Acquisition, and the Supplemental Nutrition Assistance Program

We tested the hypothesis that high costs of living, such as from high housing rents, reduce the healthfulness of food acquisitions. Using the National Household Food Acquisition and Purchase Survey (2012-13), we examined the relationships between cost of living and food acquisition patterns among both SNAP participants and non-participants (N = 5,414 individuals from households participating in SNAP, 3,863 individuals from non-participating households \u3c185% of the federal poverty threshold, and 5,036 individuals from non-participating households \u3e185% of the federal poverty threshold). Indices for cost of living included county-level Regional Price Parities for major classes of expenditures and the geographic adjustment to the Supplemental Poverty Measure, which is based on rent prices. We regressed the cost of living indices against measures of food acquisitions per person per day in each of several standard food categories, controlling for individual-, household-, and county-level characteristics. Using endogenous treatment effects models to potentially address unmeasured confounders influencing both the propensity to live in high-cost areas and patterns of food acquisition, we observed that higher area-level costs of living were associated with less healthy food acquisitions, including significantly fewer acquisitions of vegetables, fruits, and whole grains, and significantly greater acquisitions of refined grains, fats and oils, and added sugars. Overall, living in a high-cost area was associated with an 11% reduction in the Healthy Eating Index—a composite nutritional index previously associated with obesity, type II diabetes, and all-cause mortality. Additionally, we found that SNAP participation was associated with a significantly improvement in the healthfulness of food acquisitions among persons living in high-cost counties

Impact of Food Insecurity and SNAP Participation on Healthcare Utilization and Expenditures

We tested three hypothesis related to food insecurity and the Supplemental Nutrition Assistance Program (SNAP), America’s largest anti-food insecurity program. We hypothesized that 1)food insecurity would be associated with increased healthcare expenditures, 2)food insecurity would be associated with increased use of emergency department and inpatient services, and 3) SNAP participation would be associated with lower subsequent healthcare expenditures. We used data from the 2011 National Health Interview Survey linked to the 2012-13 Medical Expenditures Panel Survey. We used zero-inflated negative binomial regression to test the relationship between food insecurity and healthcare cost and use. We evaluated the association between SNAP participation and healthcare expenditures using generalized linear regression modeling, near/far matching instrumental variable analysis using state-level variation in SNAP policy as our instrument, and augmented inverse probability weighting. Those with food insecurity had significantly greater estimated mean annualized healthcare expenditures ($6,072 vs.$4,208, p\u3c0.0001), an extra $1,863 in healthcare expenditure per year, or$77.5 billion in additional healthcare expenditure annually nation-wide. Further, food insecurity was associated with significantly greater emergency department visits (Incidence Rate Ratio [IRR] 1.47, 95% Confidence Interval [CI] 1.12 – 1.93), inpatient hospitalizations (IRR 1.47, 95% CI 1.14 – 1.88), and days hospitalized (IRR 1.54, 95% CI 1.06 – 2.24). Across several analytic approaches, we found that SNAP participation was associated with reduced subsequent healthcare expenditures (best estimate: -$1,409; 95$2,694 to -$125). We conclude that food insecurity is associated with increased healthcare costs and use, and SNAP participation is associated with lower subsequent healthcare expenditures

Literacy-appropriate educational materials and brief counseling improve diabetes self-management

In this pilot study, we evaluated the impact of providing patients with a literacy-appropriate diabetes education guide accompanied by brief counseling designed for use in primary care

Goal setting in diabetes self-management: Taking the baby steps to success

To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals

Material Need Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources: Results of the Measuring Economic Insecurity in Diabetes Study

Increasing access to care may be insufficient to improve health for diabetes patients with unmet basic needs. However, how specific material need insecurities relate to clinical outcomes and care utilization in a setting of near-universal care access is unclear