Risk Factors Associated With Food Insecurity in the Medicare Population

Food insecurity is defined as the inability to obtain adequate food for explicitly financial reasons. Associations between food insecurity and worse health outcomes have been attributed to insufficient nutritional intake, trade-offs between food and medical treatment, and functional impairments.¹ Medicare enrollees, who are 65 years or older or who have long-term disabilities, are especially vulnerable to food insecurity. We present detailed national estimates of food insecurity prevalence within the Medicare population.

Data are from the 2016 Medicare Current Beneficiary Survey, administered by the US Centers for Medicare & Medicaid Services with interviews between July 25, 2016, and August 31, 2017. The Medicare Current Beneficiary Survey uses the 6-item version of the US Department of Agriculture’s food security questionnaire,² which references respondent experiences from the previous 12 months and asks if their food had ever run out, if they had no money to get more, or if they were unable to eat balanced meals, cut meal size or skipped meals, ate less than they ought, or were hungry because of insufficient money. Using an established algorithm,² our outcome designates an individual with any 2 affirmative responses as food insecure. Covariates included previously established predictors of food insecurity or difficulties affording health care.^3-5 All health-related covariates were self-reported. The Centers for Medicare & Medicaid Services administrative data contributed to demographic covariates, supplemental insurance type, and Accountable Care Organization assignment. We restricted analysis to 9674 community-dwellers with continuous 2016 Medicare enrollment who completed the food security interview, using Medicare Current Beneficiary Survey sampling weights to represent a national population of 50 685 869 community-dwelling Medicare enrollees. We separately analyzed respondents as younger than 65 years and 65 years and older. This study was approved by the Harvard Pilgrim Health Care Institutional Review Board with a waiver of informed consent.

We found that 38.3% (95% CI, 34.5%-42.1%) of enrollees younger than 65 reported food insecurity (Table 1). Other characteristics of social and clinical vulnerability (eg, income less than $15k per year, 4 or more chronic conditions, and depression) were also particularly common among enrollees younger than 65. Bivariate analyses indicated consistently high rates of food insecurity in this population, ranging 12% to 57% across all covariate strata listed in Table 1.

Among enrollees 65 years or older, 9.1% (95% CI, 8.3%-9.8%) reported food insecurity, with higher rates for especially vulnerable groups, such as income less than $15 000 (25.8%; 95% CI, 22.9%-28.7%) and Medicaid dual enrollment (33.6%; 95% CI, 30.5%-36.7%).

In multivariate logistic regression models (Table 2), all 3 lower income categories were associated with food insecurity in both groups (eg, <65 years: odds ratio [OR] for less than $15k vs $50k and over, 7.88; 95% CI, 3.32-18.71; ≥65 years: OR, 12.22; 95% CI, 7.32-20.41). Reporting 4 or more chronic conditions (<65 years: OR, 2.07; 95% CI, 1.30-3.28; ≥65 years: OR, 1.91; 95% CI, 1.33-2.76), depression (<65 years: OR, 2.65; 95% CI, 1.75-4.00; ≥65 years: OR, 1.60; 95% CI, 1.19-2.15); or anxiety (>65 years: OR, 1.72; 95% CI, 1.20-2.47; ≥65 years: OR, 1.44; 95% CI, 1.02-2.04) were also factors associated with food insecurity in both groups. In secondary models examining 10 conditions individually, diabetes showed borderline significance (OR, 1.34; 95% CI, 1.03-1.75) in the group age 65 years or older, but this result was not qualitatively different from results for less food-sensitive conditions. In secondary models adding supplemental insurance, compared with employer-sponsored insurance, Medicaid remained associated with food insecurity among enrollees age 65 years or older (OR, 3.80; 95% CI, 2.20-6.56).

Nearly 1 in 10 Medicare enrollees 65 years and older and 4 in 10 enrollees younger than 65 years experience food insecurity, suggesting both poor eating patterns that threaten health and inadequate access to other basic needs. Our estimates for older Americans are consistent with earlier reporting.⁴ Long-term disabled enrollees (<65 years) are far less studied. The pervasive food insecurity across segments within the disabled group is striking. We found disabled status, lower incomes, Medicaid dual enrollment, chronic condition burden, depression, and anxiety to be distinct factors. However, our cross-sectional analyses cannot establish causality.

These findings highlight the appropriateness of the Centers for Medicare & Medicaid Services intensifying focus on social determinants of health, exemplified by the Accountable Heath Communities model,⁶ which targets dual enrollees, and the recent expansion of allowable supplemental benefits in Medicare Advantage plans. Food insecurity screening and referral programs in clinical settings may benefit from recognition of high-risk patient groups. Autoenrollment and smoother recertification of low-income individuals could help make public efforts like the Supplemental Nutrition Assistance Program and home-delivered meals even more effective.¹ All health system innovations, including direct food provision (eg, through medically tailored meals, outpatient food pharmacies, and care packages at hospital discharge),¹ require rigorous evaluations before broader implementation.

Accepted for Publication: July 15, 2019.

Corresponding Author: Jeanne M. Madden, PhD, Associate Professor, Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, 360 Huntington Ave, R218X TF, Boston, MA 02115 (j.madden@northeastern.edu).

Published Online: September 30, 2019. doi:10.1001/jamainternmed.2019.3900

Author Contributions: Dr Madden had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Madden, Zhang, Briesacher, Ross-Degnan, Soumerai, Galbraith.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Madden.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Madden, Shetty, Zhang.

Obtained funding: Madden, Soumerai.

Administrative, technical, or material support: Madden, Shetty, Zhang, Briesacher, Galbraith.

Supervision: Madden.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was supported by a Health Equity pilot award from Northeastern University and by the National Institute on Aging (grants R01AG028745 and R01AG022362).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Jerry Gurwitz, MD (Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester), provided critical review, Caitlin Lupton, MSc (HMS/HPHC), provided administrative assistance, Xin Xu, MS (HMS/HPHC), and Farrah Nekui, MA (Northeastern), provided supportive analyses, and Debra Reed-Gillette, MS (Medicare Current Beneficiary Survey), provided insights into survey data and operations. None were compensated for contributions to this article.