Aaron E. Carroll's Blog, page 13

SNAP, WIC, and HIP: Programs of Benefit

Historically, the messaging around government food assistance programs has been muddy. The data are clear, however: Benefits for individuals and communities are significant.

Government food assistance programs often carry a negative connotation. Even their common nickname of “welfare programs” is laced with stigma. Participants have faced public ire. Critics of the programs often lob racialized stereotypes at them (e.g., the welfare queen) while debating whether or not they are “deserving” enough.

And yet, millions of Americans rely on these programs to survive. They’re proven to work, too. Government food assistance programs not only address food insecurity but also promote healthier diets, contribute to economic stability, and support community well-being. This post will review 3 major government food programs, discussing what they are as well as their connections to individual and community health.

What is SNAP?

The most well-known, the Supplemental Nutrition Assistance Program (SNAP), is a federal program that provides financial nutrition benefits to households with incomes below 200% of the federal poverty level. Formerly known as food stamps, SNAP gives participants money every month on an electronic benefits transfer (EBT) card to purchase food. However, other essential items like toiletries and household cleaners cannot be purchased.

A participant’s benefit amount is capped, and based on factors such as income, household size, and expenses. SNAP recipients must be American citizens and, barring government sanctioned reasons, will have to work up to 80 hours each month if they are between 16-59 years old.

In April 2023, over 22 million households received SNAP benefits, with an average of $343 per month per household.

What is WIC?

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is another federal program. Specifically designed for pregnant women, new mothers, infants, and children up to the age of five, the program provides both money for food and health care connections.

Participants must have an income below 185% of the FPL and a health professional or state agency must determine that they’re at nutritional risk. WIC is available regardless of immigration or citizenship status.

WIC offers a restricted food package letting people purchase pre-approved items such as infant formula, dairy products, and whole grains. State agencies also offer health-related services for participants, including connections to other social services and educational materials.

While more than six million people received the benefit in April 2023, less than 60% of people eligible for WIC were enrolled in it.

What is HIP?

While many folks are familiar with SNAP and WIC, Massachusetts’ (MA) Healthy Incentives Program (HIP) is less known. HIP gives all SNAP recipients in MA additional money each month to purchase fresh fruits and vegetables at certain farmers markets and farm stands in the state.

HIP began in 2011 as a pilot partnership program between state and federal food assistance programs. A first of its kind in the country, the pilot was successful and HIP became an official state program in 2017. Being the first program of its kind to develop, we know more about it than similar programs that started in other states later.

Since the program’s inception, more than 280,000 MA residents have utilized the program at 676 authorized locations. While those numbers may sound high, in 2021 alone, there were actually around 929,000 SNAP participants in the state. In other words, there is still plenty of room to grow.

Individual-level impacts

The impacts of government food assistance programs are most obvious at the individual level. The programs allow families to get more food, and better food. This benefits many folks with compounding expenses, like those living with disabilities for instance, leaving more money for expenses like utility bills, rent, or car maintenance.

HIP also provides more money for individuals to purchase fruits and vegetables in their local communities. This means more avenues for people to have healthy dietary options, potentially reducing health care costs.

There is a lot of discussion about the health impacts of SNAP on child and household malnutrition. This makes sense, as food insecurity is linked to many things, from the development of chronic conditions in children to increased risk of mental illness in adults. Individuals may still experience these poor outcomes when food insecurity is episodic or rare.

Beyond the food benefits, having an EBT card gives people better access to cultural hubs. For instance, in MA, EBT card holders can get into a number of museums for free or at a reduced rate. Colorado has a similar program. SNAP participants can also get admission fee waivers for college or a reduced cost Amazon Prime Membership.

Community-level impacts

Beyond the individual, these programs also positively impact communities.

At an economic level, food security programs increase the amount of goods or services that can be acquired by lower income people. This translates to community-level economic gains. For every $1.00 spent on SNAP and HIP, about $1.50 and $1.70 is generated in economic activity, respectively. Every $1.00 in WIC spending translates to about $2.50 in medical, education, and productivity savings.

HIP has also funneled millions of dollars to local farmers as a vendor-restricted program. Economic activity aside, HIP fosters a sense of community with its local emphasis.

Broadly speaking, food insecurity can significantly increase individual stress. High rates of stress lead to a host of negative outcomes for individuals, eventually spilling over into communities. This may be why some research finds that communities with lower rates of food insecurity often have lower rates of crime, better educational outcomes, and stronger local economies. At a base level these benefits make sense: When there are fewer people struggling to make ends meet, the entire community thrives.

Limitations of SNAP, WIC, and HIP

Government food assistance programs are not without flaws. The administrative rules serve as the greatest barrier for people who need help. What’s more, they often don’t even have their desired effect. For instance, recent research shows that work requirements increase the number of people exiting a program but don’t increase employment rates or reduce poverty rates.

Those working to get off of food assistance programs face strict income cut off points, creating a benefits cliff for users of the program. A benefits cliff occurs when an individual abruptly loses some or all of a benefit once they reach a certain income threshold. This happens in many government programs (including Medicaid and child care subsidies), severely impacting the well-being of low-income families and disincentivizing individuals from pursuing career opportunities or transitioning from government assistance to work.

Concluding thoughts

Government food assistance programs are vital lifelines for many Americans. SNAP and WIC ensure that low-income families have better access to essential food, reducing food insecurity and associated health risks. HIP takes it a step further by incentivizing the purchase of fresh foods from local vendors, promoting healthier dietary choices and bolstering the local economy. Together, these programs offer a limited but critical benefit to low-income people in the United States.

The post SNAP, WIC, and HIP: Programs of Benefit first appeared on The Incidental Economist.

Antidepressants, Weight Loss Drugs, and Stigma

Drugs that do a pretty good job of easing symptoms of depression and drugs that really help people struggling with obesity have a couple things in common. The first is that we have almost no idea how they work, and the second is that there’s often shame around using them because so many people view issues of mental health and weight control as personal failings. In a recent article for the New York Times I argue that we should shift focus from these two things and focus instead on significantly improving people’s lives, which these drugs do.

 



The post Antidepressants, Weight Loss Drugs, and Stigma first appeared on The Incidental Economist.

Ways We Can Mitigate Climate Change

We’ve spent a bunch of time this year examining the many, many health effects of climate change. And while we are no experts on climate change and what the best solutions are to address it, we are clearly interested in addressing it for the sake of public health. So, leaning on the works of actual climate change experts, we’re going to dig into what look like some of the most promising mitigation strategies at the moment.

 



The post Ways We Can Mitigate Climate Change first appeared on The Incidental Economist.

Cancer is not a random assault of genetic bad luck

Is cancer, the emperor of all maladies, preventable? The answer has been controversial. According to two influential studies (2015, 2017) published in Science, two thirds of cancer cases are due to intrinsic random genetic mutations during normal stem cell divisions and thus are unpreventable. The finding of these two studies gave rise to the “bad luck” theory which has been widely covered by mainstream media such as The New York Times and Los Angeles Times as well as social media.

Needless to say, the bad luck theory could have serious negative consequences for cancer prevention research and practice. Unfortunately or fortunately, the finding that two thirds of cancer cases are unavoidable is mistaken – the conclusion is derived based on a misconceived statistical metric named R-squared (R2), which is also called the coefficient of determination in statistics. The studies reached the conclusion based on the correlation between cancer incidence and random mutations during normal stem cell divisions: R2 = 0.65 (Pearson correlation coefficient (r) = 0.804), which has been universally interpreted as 65 percent of the cancer cases is explained by random mutations.

However, my recent study has demonstrated that R-squared substantially exaggerates the percent of variation in the outcome or dependent variable that is explained by the predictors or the model. In fact, with R2 = 0.65, it is about 40 percent rather than two-thirds of cancer cases that is explained by or due to random mutations and thus unpreventable.

Besides the fallacy of R-squared, studies also question the causal relationship between random genetic mutations and cancer development. For one thing, elephants or blue whales have 100 and 2,000 times more cells and random errors during cell divisions, respectively, than humans, but they rarely get cancer.

Moreover, emerging evidence indicates random mutations are not really random. A recent groundbreaking study published in the journal Nature shows organisms evolve to protect themselves and enhance survival rather than aimlessly drift.

There is no doubt that genetic mutations play a role in cancer development. For instance, BRAC1 and BRAC2 are well-recognized genetic risks for breast and ovarian cancer. However, a study published in Science revealed only about 24 percent of the mutation carriers developed breast cancer lifetime before 1940 while today the risk is over 80 percent. And keep in mind, although one cancer case is too many, according to CDC, BRAC1 and BRAC2 only contribute about three percent of all breast cancer (about 7,500 cases out of 240,000 per annum).

Other facts also contradict the bad luck theory. According to a study published by the American Cancer Society, the cancer mortality rate of all males in the US was 88.9 per 100,000 persons in 1930; by 1990, the mortality rate nearly tripled to 221.2 per 100,000. It is irrational to believe the mutation rate, or the gene pool of the nation, had changed during the 60 years. And bear in mind, the increase of cancer incident rate was likely much higher than mortality rate in the same period given the advances in cancer treatment.

Additionally, more and more younger people are diagnosed with cancer. The latest research published in 2023 by the BMJ Oncology concluded, “Global incidence of early-onset cancer increased by 79.1% and the number of early-onset cancer deaths increased by 27.7% between 1990 and 2019.”

More enlighteningly, a large cohort study published in the New England Journal of Medicine, which analyzed 44,788 pairs of twins listed in the Swedish, Danish, and Finnish twin registries, has shown the rates of cancer concordance in twins are generally below 0.1, indicating less than 10 percent of the cancers are a result of genetic factors.

Taken together, although many risk factors can contribute to cancer, it is as certain as 2 +2 = 4 that environmental factors are the principal driver behind the escalation of cancer prevalence for the last 80 years, which leads to an inescapable conclusion: most cancer cases are preventable.

In short, it cannot be any clearer that the best cure for cancer is prevention – avoiding environmental triggers.

The post Cancer is not a random assault of genetic bad luck first appeared on The Incidental Economist.

Even pro-vaxxers get worried sometimes. Why is that?

Anti-vaxxers get a lot of attention but less discussed and equally important is why many in favor of vaccines can still be hesitant about certain shots.

Vaccines work: They are one of the pillars of public health responsible for preventing disease. We’ve seen their success in the global eradication of smallpox and the near complete erasure of polio.

The majority of Americans believe that vaccines are good. Support is especially strong for childhood vaccines, such as for tetanus, diphtheria, and pertussis (Tdap) or chickenpox. When polled, most say the benefits are high and the risks are low. This – plus school requirements – translates to compliance. Most children complete the childhood vaccine schedule on time.

There are other immunizations though that feel like they don’t line up with a schedule. For example, you have to get the flu shot every year. The COVID-19 vaccine is a brand new two-shot series with annual boosters. The human papillomavirus (HPV) vaccine is another two-shot series aimed at pre-teens, though experts encourage everyone up until 26 to get it if they haven’t already.

Despite trusting in vaccines more broadly and evidence that these “off-schedule” vaccines work just as well, many people view them cautiously.

For starters, as of mid-December this year, about 41% of American adults had received their flu shot. If last year is any predictor, not many more will be getting it either.

One study asked parents to compare childhood vaccines to the flu shot. Only a quarter of parents strongly agreed that the flu shot was effective compared to 70% who believed that for childhood vaccines.

The biggest strike against the flu shot is that it doesn’t always work the way we think it should. Some people still get sick. That’s because the vaccine is made each year based on predictions of which strains of the virus will circulate in next season. Every year, it’s 40-60% effective at preventing the flu. If predictions are wrong, effectiveness suffers.

For those who still get the flu though, they likely experience a milder case. Some argue this is exactly how the flu shot is supposed to work anyway. In fact, the Centers for Disease Control and Prevention’s (CDC) promotional campaign this year is called “Wild to Mild.” But when success means you still might get sick, it’s hard to convince people to get the jab.

The COVID-19 vaccine has also struggled to gain public acceptance. To date, 78% of American adults have received at least one dose of the original COVID-19 vaccine series. That seems quite successful until you look at annual boosters. Only 20% of adults have received an updated booster so far this year.

Interestingly, politics play a big role in people’s perceptions about the COVID-19 vaccine. More than 90% of Democrats have received at least one dose of the original series while two thirds of Republicans have. About a third of Democrats received a booster this year while just over 10% of Republicans have.

Social media is also a big influencer. A study in Europe found that high trust in social media fueled COVID-19 vaccine hesitancy. Conspiracy theories – rampant online – also shaped people’s perceptions. Another report had similar findings in Africa, showing that misinformation on social media, along with religious influence and institutional mistrust, molded opinions.

The COVID-19 vaccine was developed quickly and publicly. Combined with politics and misinformation, vaccine hesitancy had fertile ground. Today, pandemic fatigue might be another explanation, as the world simply wants to move on.

Lastly, for the HPV vaccine, sexuality and novelty have made acceptance harder.

HPV is the most common sexually transmitted infection in the United States and it can cause cancer. In 2019, 54% of eligible children had completed the full vaccine series. By 2021, we had only gained four percentage points.

Some associate the vaccine itself with sexuality. In one study, one of the top five reasons parents refused the HPV vaccine for their children was because they were not yet sexually active. Another study found that a fifth of parents hadn’t had their children vaccinated for that reason. Ironically, the vaccine works best if a person receives it before they become sexually active; it might be too late otherwise.

Even though the HPV vaccine has been available for almost two decades, many still see it as new and worry about its safety. One study in France found that, even though 72% of respondents thought the vaccine was effective, 54% still had concerns about its safety or side effects. Concerns about safety actually increased from 2010 to 2018 in another study.

These trends should not be ignored, and experts should modify their approach accordingly.

Perhaps the flu shot would be more readily accepted if messaging around it was honest about what success really means (like the CDC is doing this year). Maybe more people would get their COVID-19 boosters if members of different political parties participated in promotional campaigns. And the HPV vaccine could be more palatable if it were offered when kids are even younger, when there isn’t even a suggestion of sexual activity.

Vaccines work and are crucial in the fight against preventable diseases. But human emotions and fears are real and may lead to worries about particular shots. By considering these nuances and adjusting for them, we’ll keep ourselves and future generations safe.

Research for this piece was supported by Arnold Ventures.

The post Even pro-vaxxers get worried sometimes. Why is that? first appeared on The Incidental Economist.

“Do you guys ever think about dying?”- Barbie: Advanced Care Planning & its Benefits

In the 2023 movie, Barbie recently asked: “Do you guys ever think about dying?” If you haven’t, you’re not alone, but you probably should.

End-of-life discussions are essential to providing patients, families, and providers the knowledge to respect and adhere to dying wishes. Yet, only one in three adults in the United States have any type of written instructions for their end-of-life care.

What is Advanced Care Planning?

Advanced care planning (ACP) is preparing for end-of-life medical care when someone is too ill to communicate their care preferences. Plans that are documented in writing are called advanced directives. Some advanced directives are legally binding, such as a living will or durable power of attorney for health care. They can specify someone’s health care proxy (e.g., spouse, parents, children, close friend) and do-not-resuscitate orders, which outline what should or shouldn’t be done if they can’t make their own decisions.

While ACP may be a scary and emotionally taxing process, it can also foster meaningful conversations between patients, loved ones, or providers. ACP allows everyone involved to not only consider a person’s wishes for their medical care, but their housing, assets, and finances, too.

In situations like the COVID-19 pandemic, climate disasters, or sudden medical episodes, advanced directives offer some comfort and guidance amid the scary uncertainty.

Benefits of Advanced Care Planning

The most significant benefit of ACP is that it promotes patient-centered care. Patients have more autonomy and control of how, where, and with whom they spend their last days. It helps the patient feel valued and like they’re dying with dignity. It increases the likelihood that a patient’s preferences are understood and respected, reducing the burden on families to make blind decisions for their loved ones.

ACP can also reduce the cost and improve the quality of end-of-life care for both families and hospitals. One study showed that having an advanced directive was associated with 69% less risk of longer hospitalizations. For patients in their last week of life, patient-physician end-of-life care discussions resulted in a 36% cost decrease, due to fewer expensive in-hospital and intensive care unit deaths.

Other Considerations with Advanced Directives

Advanced directives are not all legally binding, as medical appropriateness and feasibility limit providers. This may result in some care being inconsistent with a patient’s stated wishes. Nevertheless, ACP is still a valuable and important process to consider.

For those without an advanced directive, 46 states have “default surrogate consent laws” that automatically determine who makes medical decisions on a patient’s behalf in emergencies, such as a spouse or parents. Some states even expand that surrogacy to health care workers, such as nurses in Nevada and physician associates in New York.

Talking About Death

Despite the benefits of ACP, no one likes to do it.

Interestingly, we are willing to discuss being cremated, becoming an organ donor, or even debating right to die legislation. But we shy away from deeper, more logistical end-of-life discussions with our loved ones.

Given the emotional difficulty, there are lots of public resources and toolkits available to help patients, families, and providers start the conversation. Physicians can guide their patients towards the care path best aligned with their values and explain the different medical options. As a result, research shows that bereaved family members who completed an advanced directive have greater usage of hospice services and fewer concerns about physician communication.

Barbie’s question remains relevant: Are we ready for the end?

As the holiday season approaches, it’s an opportunity to gather with your loved ones and start ACP. Embracing the reality of mortality can help us make the most of our time and appreciate the present, regardless of our age. Timing also matters — each person should share this information when they’re ready, at their comfort level.

If we truly want to honor the wishes of our loved ones and patients, these conversations are necessary and shouldn’t be avoided. Barbie’s question reminds us that it’s up to of all of us to ensure we are prepared.

Research for this piece was supported by Arnold Ventures.

The post “Do you guys ever think about dying?”- Barbie: Advanced Care Planning & its Benefits first appeared on The Incidental Economist.

Aspartame and Autism?

What’s the deal with Aspartame and Autism? Whenever you see a study claiming that a single ingredient has a specific link to a specific health outcome, you should immediately feel wary. That’s because it is nearly impossible to conduct a study that provides solid evidence in support of such a claim. Let’s look at the research.

 



The post Aspartame and Autism? first appeared on The Incidental Economist.

An Overview of the PACT Act

The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act was signed into law by President Biden in August 2022. It sets out to significantly expand benefits to Veterans who have been exposed to toxins during their military service, which includes burn pits, Agent Orange, and radioactive materials. The law also devotes new resources and personnel to bolster the rural health care workforce, identifies new areas of research for toxic exposures, and creates Toxic Exposure Screenings, which are now utilized in assessing Veterans’ health histories as part of the PACT Act claims process.

The Partnered Evidence-based Policy Resource Center (PEPReC) published a policy brief outlining the PACT Act, including its implications for the Veteran community, progress in the law’s first year of implementation, and any challenges thus far. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The post An Overview of the PACT Act first appeared on The Incidental Economist.

How Can Smart Home Technology Help Older Adults to Age in Place?

What do a talking lamp and a small robot named Astro have in common? They’re not fixtures in a sci-fi movie but instead pieces of smart home technology to help older adults age in place. The amount of technology available to care for older adults is growing and can, frankly, be overwhelming to both them and their caregivers.

Care for older adults is critically important as the American population ages rapidly. From 2010 to 2020, the number of adults aged 65 years and older grew from 40.3 to 55.8 million, and will only continue to grow as the Baby Boomer generation ages.

What’s more, many more older individuals are choosing to stay at home rather than enter institutional care settings. Technology can help them do that but there are always downsides. This article will explain the pros and cons of the three most common types of technology available for older adults at home: medical alert devices, passive health monitoring, and indoor surveillance.

Medical Alert Devices

Perhaps the most popular technology used by older adults is a wearable medical alert device. When a person falls, the medical alert device either automatically detects the fall or the user presses a button. The person is then immediately connected via a two-way speaker system to emergency services (and loved ones) who can assess the situation and send the appropriate assistance. These devices help users feel supported and connected to services while still being independent and in control.

However, there are some drawbacks to using medical alert devices, the biggest being financial. There are the upfront costs and many popular alert devices also cost over $30 per month for continued monitoring. Additionally, some devices let relatives or caregivers track device activity, including the user’s location. Some older adults may find this intrusive if they wish to keep their personal health information private.

An important note about this technology is that it already exists, in part, in things like Apple watches. These devices may track certain health information and contact emergency services, which would eliminate cost barriers for those who already own such devices. They may also have already determined settings for sharing or not sharing data with loved ones and clinicians.

Passive Health Monitoring

Passive health monitoring is another tool for aging in place, utilizing artificial intelligence (AI) to remotely capture health information. In these passive systems, small and discrete sensors around the home capture data such as heart rate, gait, and blood pressure. These data can be kept private or can be shared with a physician or caregiver.

While few studies have been conducted on in-home AI outcomes, users in assisted living settings experienced fewer hospitalizations and fewer falls when AI was employed to track health data. In addition to these positive health outcomes, older adults themselves prefer these systems over things like indoor surveillance cameras because they reinforce feelings of independence, autonomy, and safety, while still capturing rich health data.

One concern with passive health monitoring technology is that data could be compromised or mishandled by those who have access to it. Additionally, the technology does not offer emergency assistance.

Indoor Surveillance Systems

Lastly, indoor cameras and sensors can be dispersed throughout the home to track movement, allow caregivers to visually check on loved ones, or ensure that doors and windows are secure. Indoor cameras not only allow caregivers to ensure their loved one is physically safe and active in the home, but they can also help spot or prevent elder abuse.

However, indoor surveillance systems may capture situations older adults would prefer to keep private, such as dressing, bathing, or intimate encounters with a partner. These systems also may be misused by relatives or caregivers to control and manage an older adult. In turn, this may reduce their sense of dignity and independence. Additionally, there is the risk that indoor cameras will be used by caregivers as a replacement for in-person assistance and social interaction.

The technology landscape for aging in place is vast and will continue to evolve. Medical alert devices, passive health monitoring, and indoor surveillance are all valuable tools when used effectively and ethically. Doing so hinges on our societal agreements about dignity, autonomy, and quality of life.

The post How Can Smart Home Technology Help Older Adults to Age in Place? first appeared on The Incidental Economist.

What Is Missing from the Inflation Reduction Act?

Prescription drugs make up a huge portion of annual Medicare spending and stress not only the federal government’s resources, but also patients and families with more limited means. To address this challenge, President Biden signed the Inflation Reduction Act (IRA) into law in 2022 which, in part, tackles drug costs. I wrote about its impact and the holes in the law recently for Health Affairs Forefront:

While the IRA is an important step forward in controlling prescription drug costs, it has some significant shortcomings. The failure to control initial launch prices for drugs and the omission of Part B drugs will continue to strain patients’ wallets, leaving them with the difficult decision of how to afford their health care.

Read the whole piece here.

Research for this article was supported by Arnold Ventures

The post What Is Missing from the Inflation Reduction Act? first appeared on The Incidental Economist.