· Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
The Supplemental Nutrition Assistance Program is an entitlement program which provides food-purchasing assistance for low and no-income people living in the United States. In 2018, SNAP benefits supplied roughly 40 million Americans with food assistance accounting for 9.2% of households and 16.7% of children in the country. In December 2019, a new rule titled Supplemental Nutrition Program: Requirements for Able-Bodied Adults without Dependents would raise the criteria to waive a requirement that SNAP recipients work at least 20 hours a week to retain their benefits. Previously, this waiver was available to recipients who lived in areas with unemployment of 7% or more, however the new rule will raise the floor unemployment rate to 10%. This change is estimated to deprive 700,000 people of their SNAP benefits.
· Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
Evaluating the effect of this policy change could have large public health implications. It may also help shed light on how SNAP benefits are distributed among families and communities, even when given to those who theoretically do not have dependents.
· Specify the outcomes and populations you think most affected or least affected by the policy.
As a pediatrician, I am most interested in how this policy change will affect health outcomes in children. While this rule change is not meant to affect households with children, it is conceivable and highly likely that SNAP recipients who do not have legal dependents use their benefits to support their children who live with a different legal guardian or their larger communities and social structures. Access to healthy food and regular meals is vital to children’s cognitive development and linear growth. Children who live in food insecure households are more likely to have developmental delays, poor educational performance and experience grade retention, and social and behavioral problems.
Of course, this policy also has a potentially large effect on the adults it effects. Poor nutrition is known to be a risk factor for obesity, type II diabetes, heart disease, stroke and all-cause mortality.
· Propose a study design to evaluate the policy.
This rule change will affect areas with unemployment between 7-10%. It may be interesting to compare data on developmental delays among pediatric patients in areas that are affected by the change and those that were not after some set amount of time (perhaps 5-10 years). We could also compare rates of severe behavioral issues and diagnosed mental illness between the two groups.
For examination of the adult population, we could examine changes in rates of obesity, type II diabetes, myocardial infarction, stroke, and all-cause mortality before and after the change goes into effect. We could also look specifically at outcomes for adults in these counties who kept their benefits vs those that didn’t, though factors related to employment for these individuals would likely have a large, confounding effect.
· Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
The biggest challenges to implementing this study would be data collection. This could be accomplished through surveys to potential participants, but this is likely to cause bias in the sample. Collecting data from the medical record would be ideal, but is very difficult with disparate health systems and need to protect patient privacy.
There are also likely to be significant effect of confounders when drawing inferences in this study. For example, some of the factors that prevent those effected by the policy change from meeting work requirements may also have effects on their underlying health.