The Supplemental Nutrition Assistance Program (SNAP) is a US federal aid program annually serving 40 million persons with well-established health, nutrition, and financial benefits.1 Families are eligible for SNAP benefits under federal rules if they have minimal assets and net incomes below the federal poverty level. Families are also required to have gross incomes below 130% of the federal poverty level; however, this requirement is waived for seniors and persons with disabilities.2,3 In 42 jurisdictions, categorical eligibility programs extend SNAP supports to otherwise ineligible families who receive benefits under certain social assistance programs, such as Temporary Assistance for Needy Families.2,3 Recently, policy makers have attempted to limit SNAP eligibility and benefits. In July 2019, the US Department of Agriculture proposed new rules limiting qualifications for categorical eligibility.2 Under the proposed rules, 1 in 10 US families currently participating in SNAP may experience discontinuation of benefits, raising concerns for adverse effects on health and the ability to pay for health care.2-4 We therefore sought to compare the health, nutritional, and financial vulnerabilities of families at risk for losing SNAP benefits with those of families meeting federal eligibility standards.
We used pooled data from the 2016-2017 Medical Expenditure Panel Survey–Household Component, a nationally representative panel survey of US households assessing sociodemographic composition, health status, and use of health care services. The survey is administered using computer-assisted personal interviewing with full-year response rates of 44% to 46% during the study period.5 Analyses used publicly available, deidentified data and were deemed exempt from review by the institutional review board of Boston Medical Center, Boston, Massachusetts.
Analyses were conducted at the family-unit level to approximate SNAP rules regarding food sharing within families. We identified SNAP participation using self-report of at least 1 month of benefits. We limited the sample to families with gross incomes of less than 200% of the federal poverty level, reflecting the upper limit for most categorical eligibility applications, and estimated net income by modeling program deductions. We dichotomized SNAP participant families into eligibility groups (categorical vs federal) based on net and gross income: categorically eligible families had net incomes above the federal poverty level and gross incomes above 130% of the federal poverty level (in families absent seniors and persons with disabilities), and the remaining families were classified as federally eligible. We compared self-reported sociodemographic factors, health status, chronic conditions, Medicaid insurance, health care–associated financial hardship (delayed or forgone care or inability to pay medical bills), and rates of food insecurity (collected as part of the survey using the US 30-day Adult Food Security Survey Module). We accounted for survey weighting, stratification, and clustering using STATA, version 14 (StataCorp LLC) to compare estimates using 2-sided Wald tests to determine statistically significant differences (P < .05).
The final cohort included 11 058 families, of which 3731 (28.3% weighted) received SNAP benefits; 3320 (88.3% weighted) were federally eligible and 411 (11.7% weighted) were categorically eligible (Table). Categorically eligible SNAP participant families had lower rates of Medicaid insurance coverage (71.4% vs 84.2%; P < .001) and more often included seniors (36.5% vs 28.5%; P = .01), compared with federally eligible families. Rates of chronic conditions (84.8% vs 84.9%; P = .98), fair to poor health status (63.7% vs 60.0%; P = .26), and health care–associated financial hardship (32.3% vs 26.7%; P = .08) were similar for categorically eligible vs federally eligible families. Food insecurity was present at high levels (30.5% vs 34.6%; P = .19) in both groups.
High rates of chronic illness, fair to poor health status, and challenges affording health care services were present among SNAP participant families at risk for losing benefits under proposed federal rules. The 2 groups of SNAP participants, despite being subject to different financial standards, demonstrated many similarities in health, nutritional, and financial needs. Categorically eligible families less often included Medicaid insurance protections against high out-of-pocket health care expenses and more often included seniors whose savings may make them ineligible under federal rules.4,6 Food insecurity, despite the moderating effects of SNAP, remained high in both groups. Erosions in SNAP supports under the proposed rules may further strain household finances, risking detrimental effects on health and affordability of care. Study limitations include imprecision replicating SNAP eligibility, with potential misclassification due to absent information on assets and family-unit designations, state-specific policies, underreporting or misreporting of benefits, and estimations for income deductions. Proposed and future SNAP eligibility policies should consider potential effects on categorically eligible families who, despite slightly higher incomes, have substantial health, nutrition, and financial needs.
Accepted for Publication: December 7, 2019.
Corresponding Author: Alon Peltz, MD, MBA, MHS, Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Dr, Ste 401 East, Boston, MA 02215 (firstname.lastname@example.org).
Published Online: March 9, 2020. doi:10.1001/jamainternmed.2019.7152
Author Contributions: Dr Peltz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Peltz, Rogers, Walsh, Garg.
Acquisition, analysis, or interpretation of data: Peltz, Galbraith, Garg.
Drafting of the manuscript: Peltz, Walsh.
Critical revision of the manuscript for important intellectual content: Peltz, Galbraith, Rogers, Garg.
Statistical analysis: Peltz.
Administrative, technical, or material support: Walsh, Garg.
Supervision: Galbraith, Garg.
Conflict of Interest Disclosures: None reported.
US Department of Agriculture, Food and Nutrition Service. Proposed rule: revision of categorical eligibility in the SNAP. https://www.fns.usda.gov/snap/fr-072419
. Posted on July 24, 2019. Accessed on September 10, 2019.
Congressional Research Service. The Supplemental Nutrition Assistance Program (SNAP): categorical eligibility. https://fas.org/sgp/crs/misc/R42054.pdf
. Updated October 25, 2019. Accessed September 10, 2019.
KL. Methodology Report 33: Sample Designs of the Medical Expenditure Panel Survey Household Component, 1996–2006 and 2007–2016. Rockville, MD: Agency for Healthcare Research and Quality; January 2019.