Food Insecurity and Health: Addressing Food Needs for Medicaid Enrollees as Part of COVID-19 Response Efforts

Issue Brief
  1. Gita Rampersad presentation. NIHCM webinar, “Food Insecurity & Growing Concerns During COVID-19” (May 11, 2020), https://www.nihcm.org/events/upcoming-events/event/food-insecurity-growing-concerns-during-covid-19.

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  2. District of Columbia v. U.S. Department of Agriculture, No. 20-119, Order (D.D.C. March 13, 2013), https://oag.dc.gov/sites/default/files/2020-03/Order-Granting-Motion-PI-SNAP-ABAWD-Rule.pdf.

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  3. The standard USDA definition for food-insecure households measures whether, at some point during the year, the household had difficulty providing enough food for all of their members due to a lack of resources. Within this group, some are further considered having “very low food security,” meaning that normal eating patterns of one or more household members were disrupted and food intake was reduced at times during the year because they had insufficient money or other resources for food. However, food insufficiency is defined using the Household Pulse Survey where respondents report sometimes or often not having enough food to eat in the past week.

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  4. Prior to the coronavirus pandemic, over one in five (22%) Medicaid enrollees experienced low food security in 2018, including 10% who reported very low food security. (KFF analysis of 2018 National Health Interview Survey)

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  5. Caroline Ratcliffe, et al. How Much Does the Supplemental Nutrition Assistance Program Reduce Food Insecurity? Am J Agric Econ 2011; 93(4): 1082-98, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4154696/.

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  6. Diane Whitmore Schanenbach and Betsy Thorn. Food Support Programs and Their Impacts on Very Young Children. Health Affairs (Bethesda, MD: March 2019): https://www.healthaffairs.org/do/10.1377/hpb20190301.863688/full/.

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  7. Craig Gundersen and James Ziliak. Food Insecurity and Health Outcomes. Health Affairs (Bethesda, MD: Nov. 2015): 34(11), https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.0645.

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  8. Food and Nutrition Service, Office of Policy Support. Supplemental Nutrition Assistance Program Food Security Survey: Impacts of Urbanicity and Food Access on Food Security (Summary) (Washington, DC: USDA, March 2014), https://fns-prod.azureedge.net/sites/default/files/SNAPFS_Summary.pdf.

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  9. Seth A. Berkowitz, et al. Participation and Health Care Expenditures among Low-Income Adults. JAMA Intern Med 2017; 177(11): 1642-49, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2653910.

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  10. Food Research & Action Center. The Role of the Supplemental Nutrition Assistance Program in Improving Health and Well-Being (Washington, DC: Dec. 2017), https://frac.org/wp-content/uploads/hunger-health-role-snap-improving-health-well-being.pdf.

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  11. Tim Bersak and Lyudmyla Sonchak. The Impact of WIC on Infant Immunizations and Health Care Utilization. Health Serv Res 2018 Aug; 53(Suppl Suppl 1): 2952-69, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056598/.

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  12. USDA Food and Nutrition Service. “About WIC – How WIC Helps,” https://www.fns.usda.gov/wic/about-wic-how-wic-helps, accessed June 30, 2020.

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  13. Silvie Colman, et al. Effects of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): A Review of Recent Research. Special Nutrition Programs Report Number WIC-12-WM (Alexandria, VA: USDA Food and Nutrition Service, Office of Research and Analysis, Jan. 2012), https://fns-prod.azureedge.net/sites/default/files/WICMedicaidLitRev.pdf.

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  14. Maureen M. Black, et al. WIC Participation and Attenuation of Stress-Related Child Health Risks of Household Food Insecurity and Caregiver Depressive Symptoms. Arch Pediatr Adolesc Med 2012; 166(5): 444-51, https://jamanetwork.com/journals/jamapediatrics/fullarticle/1151633.

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  15. Katherine Ralston, et al. Children’s Food Security and USDA Child Nutrition Programs. Economic Information Bulletin No. 174 (Washington, DC: U.S. Department of Agriculture, June 2017), https://www.ers.usda.gov/webdocs/publications/84003/eib-174.pdf?v=0.

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  16. Chantelle Bazerghi, et al. The Role of Food Banks in Addressing Food Insecurity: A Systematic Review. J Community Health 2016; 41: 732-40, https://link.springer.com/article/10.1007%2Fs10900-015-0147-5.

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  17. Julie Worthington & James Mabli. Emergency Pantry Use Among SNAP Households with Children (Princeton, NJ: Mathematica Policy Research, April 2017), https://www.mathematica.org/download-media?MediaItemId=%7B78C51BB4-8659-4D3A-A6D0-D83C20E8EB5F%7D.

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  18. Feeding America. Food Banks: Hunger’s New Staple. A Report on Visitation and Characteristics of Food Pantry Clients in the United States in 2009 (Chicago, IL: Feeding America, 2011), https://www.feedingamerica.org/sites/default/files/research/hungers-new-staple/hungers-new-staple-full-report.pdf.

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  19. Shilpa Londhe, et al. Medicaid Expansion in Social Context: Examining Relationships Between Medicaid Enrollment and County-Level Food Insecurity. J Health Care Poor Underserved 2019; 30(2): 532-46, https://www.ncbi.nlm.nih.gov/pubmed/31130536.

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  20. Gracie Himmelstein. Effect of the Affordable Care Act’s Medicaid Expansion on Food Security, 2010-2016. Am J Public Health 2019; 109(9): 1243-48, https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305168.

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  21. Data from 2018 may under-estimate or over-estimate SNAP enrollment and participation. Nationally, data indicates that SNAP enrollment declined by 2.7 people from FY2018 to FY20. However, recent data shows an uptick in enrollment between March and April 2020, returning total enrollment to levels close to 2018. https://fns-prod.azureedge.net/sites/default/files/resource-files/34SNAPmonthly-7.pdf.

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  22. District of Columbia v. U.S. Department of Agriculture, No. 20-119, Order (D.D.C. March 13, 2013), https://oag.dc.gov/sites/default/files/2020-03/Order-Granting-Motion-PI-SNAP-ABAWD-Rule.pdf.

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  23. USDA Food and Nutrition Service. “SNAP COVID-19 Emergency Allotments Guidance” (updated June 16, 2020), https://www.fns.usda.gov/snap/covid-19-emergency-allotments-guidance, accessed June 30, 2020.

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  24. USDA Food and Nutrition Service. “FNS Launches the Online Purchasing Pilot” (updated June 23, 2020), https://www.fns.usda.gov/snap/online-purchasing-pilot, accessed June 30, 2020.

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  25. USDA Food and Nutrition Service. “State Guidance on Coronavirus Pandemic EBT (P-EBT)” (updated June 2, 2020), https://www.fns.usda.gov/snap/state-guidance-coronavirus-pandemic-ebt-pebt; accessed June 30, 2020; USDA Food and Nutrition Service, “Memorandum: State Plan for Pandemic EBT (P-EBT)” (March 20, 2020), https://fns-prod.azureedge.net/sites/default/files/resource-files/SNAP-CN-COVID-PEBTGuidance.pdf.

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  26. USDA Food and Nutrition Service. “COVID-19 Congregate Meal Waivers & Q&As on Summer Meal Delivery Using Existing Authority” (updated April 4, 2020), https://www.fns.usda.gov/sfsp/covid-19/covid-19-meal-delivery, accessed June 30, 2020.

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  27. Christian A. Gregory and Alisha Coleman-Jensen, Food Insecurity, Chronic Disease, and Health Among Working-Age Adults. Economic Research Report No. 235 (Washington, DC: U.S. Department of Agriculture, July 2017), https://nopren.org/wp-content/uploads/2017/08/ERS-Report-Food-Insecurity-Chronic-Disease-and-Health-Among-Working-Age-Adults.pdf.

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  28. Janice E. Stuff, et al. Household Food Insecurity is Associated with Adult Health Status. J Nutr 2004; 134(9): 2330-35, https://www.ncbi.nlm.nih.gov/pubmed/15333724.

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  29. Christian A. Gregory and Alisha Coleman-Jensen, Food Insecurity, Chronic Disease, and Health Among Working-Age Adults (Washington, DC: U.S. Department of Agriculture Economic Research Report No. 235, July 2017), https://nopren.org/wp-content/uploads/2017/08/ERS-Report-Food-Insecurity-Chronic-Disease-and-Health-Among-Working-Age-Adults.pdf.

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  30. Hilary K. Seligman, et al. Food Insecurity is Associated with Diabetes Mellitus: Results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999-2002. J Gen Intern Med 2007; 22(7): 1018-23, https://www.ncbi.nlm.nih.gov/pubmed/17436030.

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  31. Christian A. Gregory and Alisha Coleman-Jensen, Food Insecurity, Chronic Disease, and Health Among Working-Age Adults. Economic Research Report No. 235 (Washington, DC: U.S. Department of Agriculture, July 2017), https://nopren.org/wp-content/uploads/2017/08/ERS-Report-Food-Insecurity-Chronic-Disease-and-Health-Among-Working-Age-Adults.pdf.

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  32. Craig Gundersen and James Ziliak. Food Insecurity and Health Outcomes. Health Affairs (Bethesda, MD: Nov. 2015): 34(11), https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.0645.

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  33. Christian A. Gregory and Alisha Coleman-Jensen, Food Insecurity, Chronic Disease, and Health Among Working-Age Adults. Economic Research Report No. 235 (Washington, DC: U.S. Department of Agriculture, July 2017), https://nopren.org/wp-content/uploads/2017/08/ERS-Report-Food-Insecurity-Chronic-Disease-and-Health-Among-Working-Age-Adults.pdf.

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  34. Food Research & Action Center. The Impact of Poverty, Food Insecurity, and Poor Nutrition on Health and Well-Being (Washington, DC: Dec. 2017), https://frac.org/wp-content/uploads/hunger-health-impact-poverty-food-insecurity-health-well-being.pdf.

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  35. KFF. “Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey” (March 26, 2020), https://www.kff.org/coronavirus-covid-19/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2020-findings-from-a-50-state-survey/.

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  36. Ibid.

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  37. Under “Express Lane Eligibility” (ELE), Medicaid and CHIP agencies can rely on eligibility findings from other programs, including SNAP, NSLP, and WIC, to identify, enroll, and renew coverage for children. Beyond ELE, states also have a targeted enrollment strategy option that allows them to use SNAP gross income determinations to support Medicaid income eligibility determinations at enrollment and renewal for certain individuals. Unlike ELE, this strategy does not permit states to automatically enroll or renew individuals in Medicaid based on SNAP data. Eligibility findings from Medicaid can also support enrollment in nutrition assistance programs. Under “adjunctive eligibility,” states can use Medicaid enrollment information to establish income eligibility for WIC applicants who already receive Medicaid, SNAP, or TANF, without additional income documentation. In addition, states and school districts can use income data from Medicaid files to identify students eligible for free and reduced-price meals without requiring them to submit a separate application for a school meal application to determine their income eligibility. See: Center for Medicare & Medicaid Services, Center for Medicaid and State Operations. SHO #10-003, CHIPRA #14 (Feb. 4, 2010), https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SHO10003.PDF; see also: Randy Alison Aussenberg and Julia Kortrey. A Primer on WIC: The Special Supplemental Nutrition Program for Women, Infants, and Children. (Washington, DC: Congressional Research Service, July 21, 2015), https://fas.org/sgp/crs/misc/R44115.pdf.

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  38. Medicaid may cover home-delivered meals for eligible individuals under Section 1915(i) or 1915(c) HCBS waivers,[xxxviii] but states generally cannot otherwise receive federal Medicaid funds for direct food provision.

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  39. Under federal Medicaid managed care rules, MCOs may have flexibility to pay for non-medical services through “in-lieu-of” authority and/or offer “value-added” services. “In-lieu-of” services are substitutes for covered services, count as medical costs in a plan’s medical loss ratio, and may qualify as covered services for capitation rate setting. “Value-added” services are extra services outside of covered contract services and do not qualify as covered services for the purposes of capitation rate setting, leaving plans to pay for them out of profits.

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Appendix
  1. SNAP data is a monthly average and excludes NC from January 2018 through November 2019. See: USDA Food and Nutrition Service. “Supplemental Nutrition Assistance Program” (data as of July 10, 2020), https://fns-prod.azureedge.net/sites/default/files/resource-files/SNAPsummary-7.pdf, accessed August 5, 2020.

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  2. USDA. The Special Supplemental Nutrition Assistance Program for Women, Infants and Children (WIC Program) (Washington, DC: USDA), https://fns-prod.azureedge.net/sites/default/files/wic/wic-fact-sheet.pdf, accessed June 30, 2020.

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  3. WIC data reflect a 12-month average and are current as of July 10, 2020. See: USDA Food and Nutrition Service. “WIC Program Participation and Costs” (data as of July 10, 2020), https://fns-prod.azureedge.net/sites/default/files/resource-files/wisummary-7.pdf, accessed August 5, 2020.

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  4. National School Lunch Program data reflect a nine-month average and are current as of July 10, 2020. See: USDA Food and Nutrition Service. “National School Lunch Program: Participation and Lunches Served” (data as of July 10, 2020), https://fns-prod.azureedge.net/sites/default/files/resource-files/slsummar-7.pdf, accessed August 5, 2020.

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  5. School Breakfast Program data reflect a nine-month average and are current as of July 10, 2020. See: USDA Food and Nutrition Service. “School Breakfast Program Participation and Meals Served” (data as of July 10, 2020), https://fns-prod.azureedge.net/sites/default/files/resource-files/sbsummar-7.pdf, accessed August 5, 2020.

     

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