Programs to improve health and lower cost by reducing food and housing insecurity: Do they work? What does the evidence say?

Part One:  Background and context

Preface

This blog post discusses preliminary results of an in-process review of studies that evaluate the effect of food and housing assistance programs on health status and cost.  The team consists of myself, Doug Dormer, team leader, and Kavita Shah and Amit Justi, Master’s candidates at Indiana University.  Our faculty advisor is Dr. Josette Jones, Director Health Informatics, Indiana University Purdue University at Indianapolis School of Informatics and Computing.

Intent of this blog post

I am presenting these preliminary findings in this blog post for three reasons:

  • The largest program in the US that addresses either food insecurity or housing instability is Supplemental Nutritional Assistance Program (SNAP), commonly known as “food stamps.” Assisting over 42 million people last year with a cost of about $68 billion, the Farm Bill, the law which authorizes funding for SNAP, expires on September 30.  (That is 10 days from posting this.)  Congress is currently negotiating the terms for renewal legislation. In light of the present negotiations, it is important for all of us to know the effect of SNAP and other food assistance programs on health outcomes and health cost.
  • Last Thursday, September 13, Amazon founder Jeff Bezos announced the formation of the Bezos First Day Fund, initially funded with $2 billion to help address homelessness and preschool education in the poorest communities. The fund will invest in community programs that address housing instability and homelessness.  How will the Fund measure the success of its investments in these programs.
  • While our review of the literature is still in process, we are already seeing clear patterns. We have found many studies that demonstrate that there is a relationship between food and housing anxiety and health but only a few studies that measure the effect of food or housing programs on health outcomes, health service utilization and health spending.  Of those studies we did find, by far the most studies relate to two types of programs:  SNAP for food insecurity and permanent supported housing (PSH) for housing instability.  Considering the present political pressure to reduce funding and eligibility for SNAP and permanent supported housing, understanding the effectiveness of these and other interventions and programs, possibly funded through non-federal programs, is valuable.  And there is a gap in the research.  We suspect there are studies that are in process or that have been published but that are not available in the peer-reviewed literature or that we simply have not found yet.  I hope by presenting these preliminary observations, we will invite conversation and, even better, be introduced to researchers and studies that can help answer our questions.

Background

As long as there have been people, some have been hungry or homeless.  And almost as long, there has been disagreement over the value or the harm of programs that help reduce food insecurity and housing instability.  One way of measuring the benefit or harm of food or housing programs is to look at their effect on health status including health service utilization and the total cost of care.  Do food and housing programs improve people’s health and save money or do they cost more than they save and contribute to a cycle of dependence?  What is the net return on investment for investing in food and housing benefit programs?

Since the start of the Trump Administration, this debate has been heating up as we have seen regulatory

and legislative action both supporting and opposing food and housing benefit programs along with a policy shift in leadership from federally mandated national programs to state-centric innovation and direction.

Accountable Health Communities

In early 2017, the Centers for Medicare and Medicaid Services (CMS) awarded 31 grants to organizations and communities to promote “Accountable Health Communities.” These grants funded programs to improve screening, referrals and coordination between healthcare providers and social service providers.[i]  The programs focused on the broad scope of Social Determinants of Health (SDOH) which include food and housing.  Since these programs are still fairly new in their three year lives the results have not yet been fully reported or peer-reviewed so we don’t yet know how effective these programs will be.

The Framework for Medicaid to address food insecurity and housing instability

Then, in December, 2017, the National Quality Forum, in cooperation with CMS published “A Framework for Medicaid Programs to Address Social Determinants of Health: Food Insecurity and Housing Instability” (the Framework).[ii]  The Framework recognizes that Social Determinants of Health (SDOH) generally, and food insecurity and housing instability specifically, are among the most influential factors that determine the health outcomes of individuals and proposes high-level recommendations for how state Medicaid agencies can promote participation and effectiveness in food and housing programs.[iii]  It’s not clear what impact this Framework will have.  It could give guidance about the direction of future funding opportunities from CMS and the Trump Administration.  Significantly, while the Framework did include examples of existing programs in several states, it did not point to any models or studies that could be used to quantify either the health effect or the cost impact of these interventions.  For any state Medicaid agency that is considering implementing the Framework, it would be very helpful to know what empirical results have been shown by past studies.

Restricting access to entitlement programs

At the same time, both state legislatures and Congress have either passed or are considering legislation that would limit eligibility or restrict access to food and housing benefits.  These are in addition to the general political pressure to cut budgets for all entitlement programs.  The arguments for making access more difficult include 1) too often benefits are available to people who could work but choose not to and, as a matter of public policy, should not be rewarded for failing to meet the basic responsibilities of society; 2) for all recipients, access to benefits contributes to a sense of dependence that hinders personal growth at the cost of society;  and, 3) that it is simply a bad investment to redistribute billions of dollars from those who work and are responsible to those that are not.[iv]  Thus, this policy debate has elements representing both a moral argument and an economic one.  Therefore studies that quantify the effect of food and housing programs on health outcomes and cost are critical.

The battle to renew SNAP                                

By far, the largest benefit program in the US that addresses either food insecurity or housing instability is Supplemental Nutritional Assistance Program (SNAP), commonly known as “food stamps.”  Costing over $68 billion per year and assisting over 42 million people (in 2017),[v] the Farm Bill, the law authorizing funding for SNAP, is scheduled to expire on September 30.  The renewal bill now before the House of Representatives contains changes in eligibility requirements that would cause more than 1 million low-income households with more than 2 million people — particularly low-income working families with children — to lose their benefits altogether or have them reduced.[vi]

Is HUD raising the rent?

While SNAP is the largest benefit program, similar restrictions and budget cuts are proposed for other benefit programs.  In April, Housing and Urban Development (HUD) Secretary Ben Carson proposed far-reaching changes to federal housing subsidies, tripling rent for the poorest households and making it easier for housing authorities to impose work requirements that will limit access and reduce the number of eligible beneficiaries.[vii]

Announcing the Bezos Day One Fund

And then, last Thursday, September 13, Jeff Bezos, the founder and CEO of Amazon, announced the formation of the Bezos Day One Fund, with a $2 billion commitment to focus on two areas:  “funding existing non-profits that help homeless families, and create a network of new, non-profit, tier-one preschools in low income communities.”[viii]   How will this great entrepreneur and innovator measure the success of the fund’s investments?

The big question

Looking at past programs, what is the return on investment (ROI) for investing in food our housing benefit programs?  How will we know if any of the federal or state programs, the legislative restrictions, or Mr. Bezos visionary contribution are good decisions?  Can we look to past studies to find out what to expect from any of these policy changes?

In Part Two of this blog post, we will tell you about what we’ve learned so far in our review of the literature and from our own research.

[i] Centers for Medicare and Medicaid Services, https://innovation.cms.gov/initiatives/ahcm/

[ii] A Framework for Medicaid Programs to Address Social Determinants of Health: Food Insecurity and Housing Instability.  The National Quality Forum, December 27, 2017.  http://www.qualityforum.org/ProjectDescription.aspx?projectID=85702.

[iii] Ibid.

[iv] Cohen P.  On health and welfare, moral arguments can outweigh economics.  The New York Times, 5/7/2017.  https://twitter.com/JeffBezos/status/1040253796293795842/photo/1?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1040253796293795842&ref_url=https%3A%2F%2Ffortunedotcom.wordpress.com%2Fwp-admin%2Fpost-new.php

[v] USDA Food and Nutrition Service, Supplemental Nutrition Assistance Program Participation and Costs (Data as of September 7, 2018), https://fns-prod.azureedge.net/sites/default/files/pd/SNAPsummary.pdf

[vi] Bolen E, Cai L, Dean S, et al.  House farm bill would increase food insecurity and hardship.  Center for Budget and Policy Priorities, 7/30/2018.  https://www.cbpp.org/research/food-assistance/house-farm-bill-would-increase-food-insecurity-and-hardship

[vii] Jan T, Dewey C, Stein J.  HUD Secretary Ben Carson to propose raising rent for low-income Americans receiving federal housing subsidies.  The Washington Post, 4/25/2018.  https://www.washingtonpost.com/news/wonk/wp/2018/04/25/hud-secretary-ben-carson-to-propose-raising-rent-for-low-income-americans-receiving-federal-housing-subsidies/?utm_term=.e1ee8d682318

[viii] Bezos J.  Twitter.  9/13/2018.  https://twitter.com/JeffBezos/status/1040253796293795842/photo/1?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1040253796293795842&ref_url=https%3A%2F%2Ffortunedotcom.wordpress.com%2Fwp-admin%2Fpost-new.php

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