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Vasan A, Kenyon CC, Roberto CA, Fiks AG, Venkataramani AS. Association of Remote vs In-Person Benefit Delivery With WIC Participation During the COVID-19 Pandemic. JAMA. 2021;326(15):1531–1533. doi:10.1001/jama.2021.14356
Between April and June 2020 at the start of the COVID-19 pandemic, 29.5% of children in the US, predominantly from low-income families and racial and ethnic minority groups, experienced household food insecurity.1 The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a key source of nutritional support for women and children living in poverty. WIC benefits are currently issued on electronic benefits transfer (EBT) debit cards, which can be used to purchase WIC-approved food and beverage products.
As of July 2021, 9 states (Arkansas, Louisiana, Missouri, New Mexico, Ohio, Pennsylvania, Texas, Utah, and Wyoming) require WIC beneficiaries to either mail or present these cards in person at their local WIC office every 3 to 4 months to reload their benefits (referred to subsequently as “offline states”). WIC benefits are automatically reloaded onto EBT cards remotely each month in all other states (referred to as “online states”).
Given the risks of in-person contact, delays in mail processing, and increased socioeconomic stress during the pandemic, offline benefits reloading may have limited access to WIC when the benefits were needed most.2 Because offline benefits reloading may have disincentivized participation among eligible families, we assessed whether WIC participation differed before and during the pandemic in offline vs online states.
The primary outcome was the number of WIC participants in each state per month from January 2019 to January 2021 obtained from the US Department of Agriculture (USDA) WIC monthly benefit summary. Offline vs online EBT status, the main exposure, was ascertained from USDA status reports for WIC EBT. Ten states, including 2 offline states, transitioned from paper vouchers to EBT during the pandemic and were therefore removed from the sample. State demographic characteristics were obtained from the American Community Survey and Bureau of Labor Statistics.3,4 Per University of Pennsylvania policy, institutional review board review and informed consent were not required given the use of aggregate, deidentified data.
We used a difference-in-differences strategy to estimate the adjusted mean change in WIC participation in offline states, relative to online states, before and after the start of the COVID-19 pandemic (defined as March 1, 2020). Generalized linear models were fitted using negative binomial distribution and log link and specifying state population as the exposure term, adjusting for state, month, and year.5 As a falsification test, we assessed differential trends in Supplemental Nutrition Assistance Program (SNAP) participation. SNAP is a food benefit program serving low-income households for which benefits are reloaded remotely in all states. The analyses were conducted using Stata version 15.1 (StataCorp) with 2-tailed significance set at P < .05. The 95% CIs were adjusted for clustering by state.
The final sample consisted of 40 states (7 required offline benefits reloading and 33 allowed online benefits reloading). Online and offline states had similar baseline poverty and unemployment rates and similar unemployment rates during the pandemic (Table 1). There was no statistical evidence of differing trends in WIC participation across these states prior to the pandemic (β = .0002; P = .91).
Before the pandemic, the mean number of beneficiaries was 1 275 631 in offline states and 4 018 835 in online states. During the pandemic, the mean number of beneficiaries decreased to 1 219 090 in offline states (−4.43%) and increased to 4 158 981 (3.49%) in online states. In adjusted difference-in-differences models, states with offline benefits reloading experienced a relative decrease in participation (averaged over the first 9 months of the pandemic) vs online states (−9.33% [95% CI, −14.35% to −4.31%], P < .001; Table 2). There was no significant relative change in SNAP participation in offline states (difference, 1.58% [95% CI, −2.43% to 5.59%]; P = .44).
Offline EBT reloading systems were associated with significant relative decreases in WIC participation during the COVID-19 pandemic, driven both by increased WIC participation in online states and decreased WIC participation in offline states. These findings support growing concerns that even seemingly minor barriers to accessing public programs may substantially reduce participation.2
Limitations include the observational research design, the aggregate nature of state-level administrative data, which preclude assessments of heterogenous associations between offline systems and participation, and the lack of available data on WIC eligibility during the pandemic. Nevertheless, these findings, along with prior work demonstrating that adoption of EBT debit cards in place of paper vouchers increased WIC participation,5 underscore the need for user-centered approaches to benefits design and delivery that minimize barriers to participation for low-income populations.
Corresponding Author: Aditi Vasan, MD, MSHP, Department of Pediatrics, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South St, Philadelphia, PA 19146 (email@example.com).
Accepted for Publication: August 9, 2021.
Published Online: August 20, 2021. doi:10.1001/jama.2021.14356
Author Contributions: Drs Vasan and Venkataramani had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Vasan, Roberto, Venkataramani.
Drafting of the manuscript: Vasan.
Critical revision of the manuscript for important intellectual content: Kenyon, Roberto, Fiks, Venkataramani.
Statistical analysis: Vasan, Venkataramani.
Administrative, technical, or material support: Kenyon, Fiks.
Supervision: Kenyon, Fiks, Venkataramani.
Conflict of Interest Disclosures: Dr Vasan reported receiving grants from the Academic Pediatric Association and the Agency for Healthcare Research and Quality. Dr Kenyon reported receiving grants from the National Institutes of Health. Dr Fiks reported receiving grants from the New Jersey Manufacturers Insurance Company. Dr Venkataramani reported receiving grants from the National Institutes of Health, the Center for Financial Security, Independence Blue Cross, the Robert Wood Johnson Foundation, and the Social Security Administration. No other disclosures were reported.