Geographical patterns of implementing a government subsidy program: implications for health outcomes and nutrient intake in Iran.

Introduction: The lack of access to a diverse and nutritious diet has significant health consequences worldwide. Governments have employed various policy mechanisms to ensure access, but their success varies. Method: In this study, the impact of changes in food assistance policy on food prices and nutrient security in different provinces of Iran, a sanctioned country, was investigated using statistical and econometric models. Results: Both the old and new policies were broad in scope, providing subsidized food or cash payments to the entire population. However, the implementation of these policies led to an increase in the market price of food items, resulting in a decline in the intake of essential nutrients. Particularly, the policy that shifted food assistance from commodity subsidies to direct cash payments reduced the price sensitivity of consumers. Consequently, the intake of key nutrients such as Vitamin C and Vitamin A, which are often constrained by their high prices, decreased. To improve the diets of marginalized populations, it is more effective to target subsidies towards specific nutrient groups and disadvantaged populations, with a particular focus on food groups that provide essential nutrients like Vitamin A and Vitamin C in rural areas of Iran. Discussion: More targeted food assistance policies, tailored to the specific context of each province and income level, are more likely to yield positive nutritional outcomes with minimal impact on food prices.

Are Supplemental Nutrition Assistance Program Restrictions on Sugar-Sweetened Beverages Effective in Reducing Purchase or Consumption? A Systematic Review.

The participants in the Supplemental Nutrition Assistance Program (SNAP) consume greater amounts of sugar and sweetened beverages (SSBs) compared to non-eligible individuals, which could result in potential negative health outcomes. This can be attributed to the lack of restrictions on SSB purchases with SNAP benefits. In view of the increasing calls from advocates and policymakers to restrict the purchase of SSBs with SNAP benefits, we performed a systematic review to assess its impact towards SSB purchases and consumption. We searched articles from five databases-Cochrane, EBSCO, SCOPUS, Web of Science, and PubMed-and selected seven studies, four of which were randomized controlled trials (RCTs) and three were simulation modeling studies. All three simulation studies and one RCT reported outcomes in terms of consumption, while the other three RCTs reported outcomes in terms of purchases. All seven studies found that an SSB restriction led to a decrease in SSB consumption or purchases, with six studies reporting significant results. Nonetheless, limitations exist. These include limited studies on this subject, potential workarounds circumventing SSB restrictions, like making purchases using personal cash, potentially differed estimated effects when combined with incentives or other initiatives, and the limited geographical scope among the selected RCTs.

Mixed methods evaluation of the COVID-19 changes to the WIC cash-value benefit for fruits and vegetables.

Introduction: Recent cash-value benefit (CVB) increases are a positive development to help increase WIC participant fruits and vegetables (FV) access. Little is known about the impacts of the CVB changes on FV redemptions or about implementation successes and challenges among WIC State and local agencies. This mixed method study aimed to evaluate (a) the CVB changes' impact on FV access among WIC child participants measured by CVB redemption rates, (b) facilitators and barriers to CVB changes' implementation, and (c) differences in FV redemption and facilitators and barriers by race/ethnicity. Methods: We requested redemption data from all 89 State agencies for April 2020 to September 2022 and utilized descriptive statistics, interrupted time series analysis (ITS), and generalized linear regression analysis. Additionally, we recruited State agencies, local agencies, and caregivers across the U.S. for interviews and used rapid qualitative analysis to find emerging themes anchored in policy evaluation and implementation science frameworks. Results: We received redemption data from 27 State agencies and interviewed 23 State agencies, 61 local agencies, and 76 caregivers of child WIC participants. CVB monthly redemptions increased at $35/child/month compared to $9/child/month; however, adjusted ITS analyses found a decrease in redemption rates at $35/child/month. The decrease was not significant when the transition/first implementation month was excluded with rates progressively increasing over time. Differences were found among racial/ethnic groups, with lower redemption rates observed for non-Hispanic Black caregivers. Overall, WIC caregivers reported high satisfaction and utilization at the $35/child/month. The frequent and quick turnaround CVB changes strained WIC agency resources with agencies serving higher caseloads of diverse racial and ethnic populations experiencing greater issues with implementing the CVB changes. Conclusion: Despite implementation challenges, the increased CVB shows promise to improve WIC participant FV access and satisfaction with WIC. WIC agencies need adequate lead time to update the CVB amounts, and resources and support to help ensure equitable distribution and utilization of the FV benefits.

Linking a sugar-sweetened beverage tax with fruit and vegetable subsidies: A simulation analysis of the impact on the poor.

BACKGROUND: US individuals, particularly from low-income subpopulations, have very poor diet quality. Policies encouraging shifts from consuming unhealthy food towards healthy food consumption are needed. OBJECTIVES: We simulate the differential impacts of a national sugar-sweetened beverage (SSB) tax and combinations of SSB taxes with fruit and vegetable (FV) subsidies targeted to low-income households on SSB and FV purchases of lower and higher SSB purchasers. METHODS: We considered a 1-cent-per-ounce SSB tax and 2 FV subsidy rates of 30% and 50% and used longitudinal grocery purchase data for 79,044 urban/semiurban US households from 2010-2014 Nielsen Homescan data. We used demand elasticities for lower and higher SSB purchasers, estimated via longitudinal quantile regression, to simulate policies' differential effects. RESULTS: Higher-SSB-purchasing households made larger reductions (per adult equivalent) in SSB purchases than lower SSB purchasers due to the tax (e.g., 4.4 oz/day at SSB purchase percentile 90 compared with 0.5 oz/day at percentile 25; P < 0.05). Our analyses by household income indicated low-income households would make larger reductions than higher-income households at all SSB purchase levels. Targeted FV subsidies induced similar, but nutritionally insignificant, increases in FV purchases of low-income households, regardless of their SSB purchase levels. Subsidies, however, were effective in mitigating the tax burdens. All low-income households experienced a net financial gain when the tax was combined with a 50% FV subsidy, but net gains were smaller among higher SSB purchasers. Further, low-income households with children gained smaller net financial benefits than households without children and incurred net financial losses under a 30% subsidy rate. CONCLUSIONS: SSB taxes can effectively reduce SSB consumption. FV subsidies would increase FV purchases, but nutritionally meaningful increases are limited due to low purchase levels before policy implementation. Expanding taxes beyond SSBs, providing larger FV subsidies, or offering subsidies beyond FVs, particularly for low-income households with children, may be more effective.

Effectiveness of unconditional cash transfers combined with lipid-based nutrient supplement and/or behavior change communication to prevent stunting among children in Pakistan: a cluster randomized controlled trial.

BACKGROUND: In Pakistan, the prevalence of stunting among children younger than 5 y has remained above WHO critical thresholds (≥30%) over the past 2 decades. OBJECTIVES: We hypothesized that an unconditional cash transfer (UCT) combined with lipid-based nutrient supplement (LNS) and/or social and behavior change communication (SBCC) will prevent stunting among children 6-23 mo of age. METHODS: This was a 4-arm, community-based cluster randomized controlled trial conducted in the district of Rahim Yar Khan, Pakistan. A total of 1729 children (UCT, n = 434; UCT + SBCC, n = 433; UCT + LNS, n = 430; and UCT + LNS + SBCC, n = 432) were enrolled at 6 mo of age and measured monthly for 18 mo until the age of 24 mo. RESULTS: At 24 mo of age, children who received UCT + LNS [rate ratio (RR): 0.85; 95% CI: 0.74, 0.97; P = 0.015) and UCT + LNS + SBCC (RR: 0.86; 95% CI: 0.77, 0.96; P = 0.007) had a significantly lower risk of being stunted compared with the UCT arm. No significant difference was noted among children who received UCT + SBCC (RR: 1.03; 95% CI: 0.91, 1.16; P = 0.675) in the risk of being stunted compared with the UCT arm. The pooled prevalence of stunting among children aged 6-23 mo was 41.7%, 44.8%, 38.5%, and 39.3% in UCT, UCT + SBCC, UCT + LNS, and UCT + LNS + SBCC, respectively. In pairwise comparisons, a significant impact on stunting among children in UCT + LNS (P = 0.029) and UCT + LNS + SBCC (P = <0.001) was noted compared with the UCT arm. CONCLUSIONS: UCT combined with LNS and UCT + LNS + SBCC were effective in reducing the prevalence of stunting among children aged 6-23 mo in marginalized populations. UCT + SBCC was not effective in reducing the child stunting prevalence. This trial was registered at clinicaltrials.gov as NCT03299218.

"Now I Feel a Little Bit More Secure": The Impact of SNAP Enrollment on Older Adult SSI Recipients.

In June 2019, California expanded Supplemental Nutrition Assistance Program (SNAP) eligibility to Supplemental Security Income (SSI) beneficiaries for the first time. This research assesses the experience and impact of new SNAP enrollment among older adult SSI recipients, a population characterized by social and economic precarity. We conducted semi-structured, in-depth interviews with 20 SNAP participants to explore their experiences with new SNAP benefits. Following initial coding, member-check groups allowed for participants to provide feedback on preliminary data analysis. Findings demonstrate that SNAP enrollment improved participants' access to nutritious foods of their choice, contributed to overall budgets, eased mental distress resulting from poverty, and reduced labor spent accessing food. For some participants, SNAP benefit amounts were too low to make any noticeable impact. For many participants, SNAP receipt was associated with stigma, which some considered to be a social "cost" of poverty. Increased benefit may be derived from pairing SNAP with other public benefits. Together, the impacts of and barriers to effective use of SNAP benefits gleaned from this study deepen our understanding of individual- and neighborhood-level factors driving health inequities among low-income, disabled people experiencing food insecurity and SNAP recipients.

Supplemental Nutrition Assistance Program Participation and Health Care Use in Older Adults : A Cohort Study.

BACKGROUND: Older adults dually eligible for Medicare and Medicaid have particularly high food insecurity prevalence and health care use. OBJECTIVE: To determine whether participation in the Supplemental Nutrition Assistance Program (SNAP), which reduces food insecurity, is associated with lower health care use and cost for older adults dually eligible for Medicare and Medicaid. DESIGN: An incident user retrospective cohort study design was used. The association between participation in SNAP and health care use and cost using outcome regression was assessed and supplemented by entropy balancing, matching, and instrumental variable analyses. SETTING: North Carolina, September 2016 through July 2020. PARTICIPANTS: Older adults (aged ≥65 years) dually enrolled in Medicare and Medicaid but not initially enrolled in SNAP. MEASUREMENTS: Inpatient admissions (primary outcome), emergency department visits, long-term care admissions, and Medicaid expenditures. RESULTS: Of 115 868 persons included, 5093 (4.4%) enrolled in SNAP. Mean follow-up was approximately 22 months. In outcome regression analyses, SNAP enrollment was associated with fewer inpatient hospitalizations (-24.6 [95% CI, -40.6 to -8.7]), emergency department visits (-192.7 [CI, -231.1 to -154.4]), and long-term care admissions (-65.2 [CI, -77.5 to -52.9]) per 1000 person-years as well as fewer dollars in Medicaid payments per person per year (-$2360 [CI, -$2649 to -$2071]). Results were similar in entropy balancing, matching, and instrumental variable analyses. LIMITATION: Single state, no Medicare claims data available, and possible residual confounding. CONCLUSION: Participation in SNAP was associated with fewer inpatient admissions and lower health care costs for older adults dually eligible for Medicare and Medicaid. PRIMARY FUNDING SOURCE: National Institutes of Health.

Philadelphia's Excise Tax on Sugar-Sweetened and Artificially Sweetened Beverages and Supplemental Nutrition Assistance Program Benefit Redemption.

Objectives. To assess the effect of a 2017 excise tax on sugar and artificially sweetened beverages in Philadelphia, Pennsylvania, on the shopping patterns of low-income populations using Supplemental Nutrition Assistance Program (SNAP) data. Methods. I used a synthetic controls approach to estimate the effect of the tax on Philadelphia and neighboring Pennsylvania counties (Bucks, Delaware, and Montgomery) as measured by total SNAP sales ("SNAP redemption") and SNAP redemption per SNAP participant. I assembled biannual data (2005-2019) from all US counties for SNAP redemption and relevant predictors. I performed placebo tests to estimate statistically significant effects and conducted robustness checks. Results. Detectable increases in SNAP spending occurred in all 3 Philadelphia neighboring counties. Per-participant SNAP spending increased in 2 of the neighboring counties and decreased in Philadelphia. These effects were robust across multiple specifications and placebo tests. Conclusions. The tax contributed to increased SNAP shopping in Philadelphia's neighboring counties across both outcome measures, and decreased spending in Philadelphia (at least by 1 measure). This raises questions about retailer behavior, the effectiveness of the tax's public health aim of reducing sugar-sweetened beverage consumption, and policy aims of investing in low-income communities. (Am J Public Health. 2021;111(11):1986-1996. https://doi.org/10.2105/AJPH.2021.306464).

Association of a Fruit and Vegetable Subsidy Program With Food Purchases by Individuals With Low Income in the US.

Importance: Food insecurity is associated with a less healthy diet. The Supplemental Nutrition Assistance Program (SNAP) is associated with reduced food insecurity, but benefit levels may be insufficient for beneficiaries to afford healthy foods. Objective: To evaluate whether participation in SuperSNAP, a program that provides an additional $40 per month for the purchase of fruits and vegetables with no added sugar, sodium, or fat to SNAP beneficiaries, is associated with changes in food purchasing. Design, Setting, and Participants: This longitudinal cohort study used data from transaction records of a large supermarket chain with approximately 500 stores located across North Carolina from October 2019 to April 2020. Participants were SNAP beneficiaries. Exposure: SuperSNAP participation. Main Outcomes and Measures: Monthly spending on all fruits, vegetables, legumes, and nuts (primary outcome); spending on less healthy food categories; and spending on sugar-sweetened beverages as 1 category of less healthy foods. Monthly data on purchases by SNAP beneficiaries before and during SuperSNAP participation were compared with data from SNAP beneficiaries not enrolled in the program who shopped at the same stores. Overlap weighting (a propensity score-based method) was used to account for confounding, and linear mixed-effects models were fitted with random effects to account for repeated measures and clustering by store. Results: The study included 667 SuperSNAP participants and 33 246 SNAP beneficiaries who did not use SuperSNAP but shopped in the same stores; 436 SuperSNAP participants had preintervention data and were included in the main analysis. SuperSNAP participation was associated with increased monthly purchases of fruits, vegetables, nuts, and legumes ($31.84; 95% CI, $31.27-$32.42; P < .001; 294.52 oz; 95% CI, 288.84-300.20 oz; P < .001). Only a small increase in spending on less healthy food categories compared with the SNAP beneficiaries who did not use SuperSNAP ($1.60; 95% CI, $0.67-$2.53; P < .001) was observed. As total spending increased, the proportion of total food and beverage spending on less healthy foods significantly decreased (difference, 4.51%; 95% CI, 4.27%-4.74%; P < .001). Monthly spending on sugar-sweetened beverages decreased (difference, $1.83; 95% CI, $1.30-$2.36; P < .001). Conclusions and Relevance: In this cohort study, participation in SuperSNAP was associated with meaningful increases in healthy food purchasing. Subsequent studies should investigate whether healthy food incentive programs improve health outcomes.

Acceptability and Willingness to Pay for a Meal Kit Program for African American Families with Low Income: A Pilot Study.

Food insecurity is a persistent issue among individuals with low income and is associated with various nutrition- and health-related consequences. Creative approaches to increasing food access should be investigated as possible solutions. Meal kits, which are boxes or bags of fresh and shelf-stable ingredients for one or more meals, along with a step-by-step recipe showing how to cook each meal at home, may serve as a creative solution. Meal kits have historically been marketed to higher-income demographics. The purpose of this pilot study was to investigate the utilization, acceptability, and willingness to pay for a healthy meal kit program among African American main food preparers with children and low income (n = 36). Participants received a healthy meal kit with three recipes and ingredients, a cooking incentive, and a nutrition handout weekly for six weeks. Data were collected on participants' use, acceptability, and willingness to pay for the meal kits and analyzed using descriptive statistics. The intervention was highly utilized, and participants reported high acceptability ratings for most recipes. After the intervention, participants were willing to pay $88.61 ± 47.47 for a meal kit with three meals, each with four portions, which was higher than indicated at baseline and similar to the cost to produce the kits. Meal kits may offer a creative solution to improving food access if affordable for families with low income.

Association of Funding and Meal Preparation Time With Nutritional Quality of Meals of Supplemental Nutritional Assistance Program Recipients.

Importance: The Supplemental Nutrition Assistance Program (SNAP) is a federal program that provides food-purchasing assistance to low-income people; however, its current design does not account for the time availability of SNAP recipients to prepare meals. Objective: To evaluate the association of the availability of funding for food purchases and time for meal preparation with the nutritional quality of meals of SNAP recipients. Design, Setting, and Participants: This study used decision analytical modeling to evaluate the nutritional quality of meals of SNAP recipients. The model was developed from February 6, 2017, to December 12, 2020, using data from 2017 and is based on discrete optimization. The model describes food and grocery purchasing, in-home meal preparation, and meal plan choices of a family of SNAP participants (2 adults and 2 children) while considering food preferences, meal preparation time, and food costs. The model assumes food preferences match the foods typically purchased by SNAP households. Costs of food ingredients and prepared foods are taken from a single zip code. Exposures: Time availability and total amount and type of funding were varied. Allowing prepared delicatessen foods and disallowing frozen prepared foods for purchase using SNAP funds were considered. Main Outcomes and Measures: The primary outcome was the number of home-cooked meals and the amounts of fruits, vegetables, protein, sodium, sugar, and fiber consumed from generated meal plans. Amounts were evaluated as a percentage of the quantity recommended by established dietary guidelines. Results: Increased time availability was associated with increases in the percentage of home-cooked meals and servings of fruits/vegetables and decreased sodium consumption. Higher levels of funding were associated with increased consumption of fiber, fruits/vegetables, protein, sodium, and sugar. With 20 min/d of cooking time, $400/mo of SNAP benefits, and $100/mo of self-funding, the meal plan had a mean (SE) of 20.1% (0.3%) of meals home cooked, 0.5 (<0.1) servings/d per person of fruits/vegetables, 100.3% (0.6%) of daily recommended protein per person, 115.1% (0.8%) of daily recommended sodium per person, 241.8% (1.0%) of daily recommended sugar per person, and 31.2% (0.3%) of daily recommended fiber per person. With 20 min/d of cooking time, $400/mo of SNAP benefits, and $600/mo of self-funding, the meal plan had a mean (SE) of 23.9% (1.0%) of meals home cooked, 2.8 (0.1) servings/d per person of fruits/vegetables, 134.9% (1.6%) of daily recommended protein per person, 200.9% (3.1%) of daily recommended sodium per person, 295.1% (3.1%) of daily recommended sugar per person, and 90.1% (1.0%) of daily recommended fiber per person. With 60 min/d of cooking time, $400/mo of SNAP benefits, and $100/mo of self-funding, the meal plan had a mean (SE) of 52.7% (0.9%) of meals home cooked, 1.4 (<0.1) servings/d per person of fruits/vegetables, 109.0% (1.1%) of daily recommended protein per person, 108.7% (1.0%) of daily recommended sodium per person, 298.6% (2.0%) of daily recommended sugar per person, and 38.8% (0.4%) of daily recommended fiber per person. With 60 min/d of cooking time, $400/mo of SNAP benefits, and $600/mo of self-funding, the meal plan had a mean (SE) of 42.8% (1.2%) meals home cooked, 4.3 (0.1) servings/d per person of fruits/vegetables, 144.4% (1.8%) of daily recommended protein per person, 165.2% (2.8%) of daily recommended sodium per person, 322.4% (2.4%) of daily recommended sugar per person, and 91.0% (0.9%) of daily recommended fiber per person. Conclusions and Relevance: In this decision analytical model, meal preparation time was associated with the ability of SNAP recipient families to consume nutritious meals, suggesting that increased funding alone may be insufficient for improving the nutritional profiles of SNAP recipients. Given the current US food supply, governmental interventions that provide the equivalence in increased time availability to achieve nutritious meals may be needed.

The American Rescue Plan Act Is a Great Start but More Increases in Supplemental Nutrition Assistance Program (SNAP) Benefits Are Likely Needed Due to Implicit Hidden Reductions.

The Supplemental Nutrition Assistance Program (SNAP) is intended to help low-income individuals reach the cost of a nutritious diet. In response to the Coronavirus disease 2019 (COVID-19) pandemic, SNAP benefits have been increased by 20.3% since October 2020. Given the intended goal of the program, is the 20.3% increase enough? Even prior to COVID-19, the literature had identified 3 separate shortcomings in the current formula that had not been addressed. Here, these shortcomings are integrated into a unifying framework that allows for a comparison between an adjusted formula, that accounts for all these shortcomings, and the current unadjusted formula, that does not account for these shortcomings. Using some average data from the literature, the current unadjusted formula gives the misleading impression that the government will provide 71% of the cost of a nutritious diet with households responsible for 29%. However, working with the adjusted formula, that takes into account the shortcomings, reveals the government actually only provides 41% of the adjusted cost of a nutritious diet and households are responsible for 59%. Some actual and recommended adjustments are shown to fall far short of the full adjustment required to reach a nutritious diet, on average. In particular, the 20.3% increase is less than half of the amount needed to fully correct for these omissions.

Association of loss of Supplemental Nutrition Assistance Program benefits with food insecurity and dietary intake of adults and children.

BACKGROUND: Supplemental Nutrition Assistance Program (SNAP) disenrollment among income-eligible households could limit their ability to access food. OBJECTIVES: To assess the association of loss of SNAP benefits on food security status and dietary intake of household members, using 2011-2016 NHANES data. METHODS: SNAP participation status among those with a household income ≤130% of the federal poverty level was categorized as 1) current participants, 2) former participants with benefits cut off in the past year, and 3) former participants with benefits cut off for more than a year. Logistic regression examined associations of SNAP participation status with odds of household (n = 7387), adult (n = 7387), and child (n = 5898) food security. Linear regression examined associations of participation status with Healthy Eating Index-2015 (HEI-2015) total and component scores in adults (n = 2784) and children/adolescents (n = 2553). RESULTS: Former SNAP participants with benefits cut off in the past year had greater odds of severe household (OR: 2.18; 95% CI: 1.25, 3.78) and adult (OR: 2.09; 95% CI: 1.24, 3.54) food insecurity compared with current participants. Benefit cutoff in the past year was significantly related to low child food security (OR: 1.80; 95% CI: 1.04, 3.11) and lower child/adolescent greens and beans score (estimate: -0.40; SE: 0.18). Loss of benefits for more than a year was significantly associated with increased marginal child food security odds (OR: 2.07; 95% CI: 1.23, 3.47), lower adult dairy score (estimate: -0.63; SE: 0.24), and lower child/adolescent greens and beans (estimate: -0.34; SE: 0.16), whole grains (estimate: -0.50; SE: 0.21), and dairy scores (estimate: -0.93; SE: 0.29). CONCLUSIONS: This study suggests that loss of benefits may increase household food insecurity. Although child/adolescent intakes of certain HEI-2015 adequacy components were lower among former SNAP participants, overall diet quality score did not differ. Findings collectively imply the need for policies that protect households from the adverse effects of benefits loss.

Association of WIC Participation and Electronic Benefits Transfer Implementation.

Importance: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is an important source of nutritional support and education for women and children living in poverty; although WIC participation confers clear health benefits, only 50% of eligible women and children currently receive WIC. In 2010, Congress mandated that states transition WIC benefits by 2020 from paper vouchers to electronic benefits transfer (EBT) cards, which are more convenient to use, are potentially less stigmatizing, and may improve WIC participation. Objective: To estimate the state-level association between transition from paper vouchers to EBT and subsequent WIC participation. Design, Setting, and Participants: This economic evaluation of state-level WIC monthly benefit summary administrative data regarding participation between October 1, 2014, and November 30, 2019, compared states that did and did not implement WIC EBT during this time period. Difference-in-differences regression modeling allowed associations to vary by time since policy implementation and included stratified analyses for key subgroups (pregnant and postpartum women, infants younger than 1 year, and children aged 1-4 years). All models included dummy variables denoting state, year, and month as covariates. Data analyses were performed between March 1 and June 15, 2020. Exposures: Statewide transition from WIC paper vouchers to WIC EBT cards, specified by month and year. Main Outcomes and Measures: Monthly number of state residents enrolled in WIC. Results: A total of 36 states implemented WIC EBT before or during the study period. EBT and non-EBT states had similar baseline rates of poverty and food insecurity. Three years after statewide WIC EBT implementation, WIC participation increased by 7.78% (95% CI, 3.58%-12.15%) in exposed states compared with unexposed states. In stratified analyses, WIC participation increased by 7.22% among pregnant and postpartum women (95% CI, 2.54%-12.12%), 4.96% among infants younger than 1 year (95% CI, 0.95%-9.12%), and 9.12% among children aged 1 to 4 years (95% CI, 3.19%-15.39%; P for interaction = .20). Results were robust to adjustment for state unemployment and poverty rates, population, and Medicaid expansion status. Conclusions and Relevance: In this study, the transition from paper vouchers to WIC EBT was associated with a significant and sustained increase in enrollment. Interventions that simplify the process of redeeming benefits may be critical for addressing low rates of enrollment in WIC and other government benefit programs.

Universal Free Meals Associated with Lower Meal Costs While Maintaining Nutritional Quality.

The Community Eligibility Provision (CEP) of the Healthy, Hunger-Free Kids Act of 2010 allows the provision of universal free meals (UFMs) in high-poverty school areas. Participation in UFM programs, including through CEP, could reduce meal costs due to economies of scale and a lower administrative burden. We analyzed the School Nutrition and Meal Cost Study (SNMCS) data from 508 UFM-eligible schools (103 UFMs) to evaluate whether meal costs varied by UFM status. We used school-level data to address the non-random selection to UFMs with inverse probability of treatment weighting (IPTW). We estimated a generalized linear model with a log link and gamma distribution to predict meal costs by UFM status and school size. Full costs among medium and large schools were marginally lower in UFM schools for lunch (-$0.673; 95% CI: -1.395, 0.0499; p = 0.068) and significantly lower for breakfast (-$0.575; 95% CI: -1.077, -0.074; p = 0.025). UFM was not associated with meal costs among smaller schools. Healthy Eating Index scores did not vary significantly by UFMs, suggesting that lower costs could be achieved without an adverse effect on nutritional quality. This analysis is limited by the lack of identified student percentage (ISP) data needed to definitively identify CEP eligibility, although results were robust to sensitivity analyses addressing the lack of ISP data. The potential policy impact of these findings emphasizes the need for future studies that assess ISP and cost with more recent data and longitudinal designs.