Examining the bidirectional relationship between food insecurity and healthcare spending

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      In this study of nationally representative data, we found support for both directions of the relationship between food insecurity and healthcare expenditures—food insecurity is associated with greater health care expenditures, and greater health care expenditures are associated with food insecurity. However, the strength of these associations appears to be unequal. Though we found a statistically significant association between health care expenditures and subsequent food insecurity, the difference in odds was small—about 1% greater risk of food insecurity per $1000 difference in health care expenditures. When examining the association between food insecurity and subsequent health care expenditures, the difference in expenditures between food insecure and food secure participants was relatively larger—approximately 25% greater expenditures for those who were food insecure. This suggests that upstream efforts that seek to address food insecurity may have greater impact than downstream efforts that seek to address health care expenditures directly.

      Expenditures for prescriptions made up the largest share of the difference in health care spending between those who were food insecure and those who were food secure. Furthermore, with regard to the relationship between health care expenditures (as predictor) and food insecurity status (as outcome), we found evidence that greater health care expenditures may be an indicator of underlying poor health status. In models that adjusted for both indicator health care expenditures and indicators of poor health (eg, disability) the association between health care expenditures (as predictor) and food insecurity status (as outcome) was weakened, while the association between disability and subsequent food insecurity was strong. This suggests that high health care expenditures may be associated with food insecurity risk because they indicate poor health (which can impair the ability to work), rather than because they drain household resources directly. The finding that out‐of‐pocket expenditures is not associated with food insecurity risk also supports this idea.

      The results of this study have several implications. First, the confluence of comorbidities, health care expenditures, and food insecurity suggests that attempting to address food insecurity without paying attention to comorbidity could limit the effectiveness of the intervention. Rather than viewing food insecurity as one standalone issue to address, it may be more effective to think of addressing food insecurity as one aspect of a more comprehensive disease management plan. Relatedly, given that the strength of the association appears larger when food insecurity is the predictor and greater health care expenditures is the outcome (compared with when these roles are reversed), disease management plans, which target the upstream determinants of food insecurity and general poor health, may be more efficacious at breaking this cycle than interventions that merely offset the cost of disease management. Thirdly, the category of prescription expenditures stands out in our analyses. One reason for this may be that if food insecurity increases the risk for the development or worsening of chronic conditions, it could lead to increasingly complicated medication regimens, with attendant costs. Finally, the lack of association between out‐of‐pocket expenditures and food insecurity, coupled with a strong association between medical debt and food insecurity, warrants closer attention. Current insurance benefit design often considers out‐of‐pocket expenditures (eg, yearly out‐of‐pocket maximums set at an absolute number) without considering medical debt. More nuanced design that takes into account an individual’s ability to match resources to expenditures (eg, yearly out‐of‐pocket maximums set as a percentage of income or assets) may better protect individuals from the consequences of out‐of‐pocket costs.

      The presence of these relationships sets up the potential for a self‐reinforcing “vicious cycle” whereby food insecurity worsens health and worse health increases the risk for food insecurity. Given the different directional associations, however, interventions targeted at addressing food insecurity as a part of chronic disease management may be a more promising way to break this cycle and improve health for disadvantaged individuals.

      Comment by Don McCanne of PNHP: We’ve long known that food insecurity is a major problem that can have a significant impact on a patient’s health. This HSR study shows that food insecurity is associated with higher health care expenditures. That certainly should catch the attention of the private health insurers, and it has.

      Avalere reports that private Medicare Advantage plans are now offering “non-primarily health-related supplemental benefits to beneficiaries with chronic illnesses.” The most commonly offered benefits are meals (45% of plans, enrolling 1.5 million beneficiaries), and food and produce (43% of plans enrolling 1.9 million beneficiaries).

      We have continued to sit back and watch the private insurance industry take over significant portions of the health care delivery industry. Now are we going to continue to sit back as we watch them take over the food industry as well?

      I’d say that enacting and implementing a single payer system of improved Medicare for All has become an emergency, lest the out-of-control steamroller wipes out more of us.

      Jesus: Hey, Dad? God: Yes, Son? Jesus: Western civilization followed me home. Can I keep it? God: Certainly not! And put it down this minute--you don't know where it's been! Tom Robbins in Another Roadside Attraction

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