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Health Affairs Editor-in-Chief Alan Weil interviews Deepak Palakshappa, associate professor at Wake Forest School of Medicine on his paper in the January 2023 issue examining the relationship between food insecurity and health care expenditures in families.
Each week, Health Affairs Editor-in-Chief Alan Weil brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;01 - 00;00;32;02
Alan Weil
Hello and welcome to A Health Podyssey. I'm your host, Alan Weil. About 10% of all households in the United States experienced low or very low food security in 2021. That means that, according to the U.S. Department of Agriculture, about one in ten households has inadequate access to enough food for an active, healthy life. These rates are higher for black households with a food insecurity rate of almost 20%.
00;00;32;17 - 00;00;58;24
Alan Weil
The rates about 16% for Hispanic households. Now we know that access to adequate healthy food is an important precursor for good health. Studies have shown a relationship for adults between food insecurity and higher health spending. But food insecurity is a household phenomenon. It affects everyone in the home. How does household level food insecurity relate to health spending for the entire household?
00;00;59;04 - 00;01;30;23
Alan Weil
That's the question we'll discuss in today's episode of A Health Podyssey. I'm here with Deepak Palakshappa, associate professor in the Department of Internal Medicine at Wake Forest School of Medicine. Dr. Palakshappa and coauthors published a paper in the January 2023 issue of Health Affairs, examining the relationship between food insecurity and health care expenditures in families. They found higher health care spending in food insecure households, and this was the case across types of spending and types of insurance.
00;01;31;05 - 00;01;36;26
Alan Weil
We'll discuss these findings in today's episode. Dr. Palakshappa, welcome to the program.
00;01;37;21 - 00;01;38;24
Dr. Palakshappa
Thank you so much for having me.
00;01;39;15 - 00;02;02;11
Alan Weil
I appreciate the work you're doing in this area. And for those who don't focus on food, are more interested in sort of other aspects of health, maybe we should just start with the concept of food insecurity. What does that mean? It's sort of a technical term. And given what it means, why would we think it could be related to what families spend on health care?
00;02;02;27 - 00;02;24;23
Dr. Palakshappa
Yeah, absolutely. So as you mentioned, food insecurity is defined by the USDA as a limited or uncertain availability of nutritionally adequate and safe foods and a lack of access to enough foods for a healthy life. And what that basically means is essentially constantly worrying about having enough food at home. I mean, I think that's the main message here.
00;02;24;25 - 00;02;46;24
Dr. Palakshappa
And as you said, one in ten households in the U.S. are food insecure, which still sort of blows my mind that in a country with this much wealth, how is it possible that one in ten households still struggle to have enough food at home? And that's even worse for households with children, as households with children have higher rates of food insecurity than just for the general U.S. households.
00;02;47;28 - 00;03;12;12
Dr. Palakshappa
Now, over the last for 10 to 15 years, there's also been this growing research, specifically looking at the relationship between food insecurity and health care outcomes. And what we see is that food insecurity is associated with poor health across the life course. So from pregnancy to older adults, food insecurity has been associated with worse health, impaired chronic disease management, as well as increased health care expenditures.
00;03;13;05 - 00;03;53;24
Dr. Palakshappa
Now, the exact why or how food insecurity leads to these sort of worse health outcomes is still sort of a question of debate. But, you know, there's certainly several possibilities. I mean, I think the sort of more intuitive idea is this idea around diet and nutrition. So if you're worried about having enough food, if you have a limited food budget, you're often forced to buy sort of cheap, often unhealthy, high calorie foods that lead to increased weight gain issues such as diabetes, hypertension, that can all sort of increase your need to seek health care, either for medication management or because you need to be hospitalized for some reason.
00;03;54;29 - 00;04;16;27
Dr. Palakshappa
But there's some other aspects, too, around food insecurity that I think we, that aren't so sort of clear or sort of intuitive. And the second thing being kind of just the stress around having enough food. So the constant worry about being able to provide for your family is a particularly an issue for parents and mothers about feeling sort of shame and guilt around being able to provide food for their children.
00;04;17;10 - 00;04;43;29
Dr. Palakshappa
And this risk, stress and shame leads to increased anxiety, depression and just worse, overall health. And then finally, I think just sort of that sort of constant worry about being able to afford food leads to worries about being able to afford other goods and services, particularly like health care. So your people are often forced to sort of decide like, do I go pay for my preventative health care visit or do I pay for the food in the house?
00;04;44;11 - 00;05;11;03
Dr. Palakshappa
And a lot of parents and a lot of adults and in many times make that choice to say no, I'm going to pay for the food in the house because that's the immediate need and end up delaying seeking sort of preventative care. So many of the sort of health issues that could have been handled as sort of an outpatient basis ultimately ends up getting them admitted to the hospital or in the emergency room because they've often waited too late to sort of address those things.
00;05;12;03 - 00;05;44;22
Alan Weil
I really appreciate you describing these various pathways. I think it's sort of easy to say, sure, families have to struggle with food, probably have bigger health challenges, but it's quite complex. And in that context, your study focused on family spending and all the examples you gave were very sort of family oriented. So can you say a little bit more to me about how this work differed from other work that's been done on food insecurity and health spending?
00;05;45;08 - 00;06;11;29
Dr. Palakshappa
Sure. Absolutely. So as you mentioned, the food insecurity is like is a household measure. And so despite people in the households best efforts, all people in the household are potentially negatively impacted by food insecurity. And families try to make difficult decisions and often try to protect individuals in the household. But that often doesn't work. A great example is parents, parents and guardians.
00;06;12;21 - 00;06;36;19
Dr. Palakshappa
They'll often skip meals, cut the size of their own meals to make sure that their kids get food. But studies have shown that despite parents making these sort of sacrifices for their children, the children are often aware of what's going on and know that the family is struggling to have food and again, feel the anxiety and stress that comes around not having food.
00;06;36;25 - 00;07;07;23
Dr. Palakshappa
And so everybody in the household is at risk of sort of the negative impacts of food insecurity. Prior studies have primarily focused on sort of individual level outcomes, particularly several studies recently that have shown that food insecurities are associated with increased individual health care costs or health care expenditures. And that's actually led to several sort of health systems and health insurers sort of investing in interventions to try to address their patients’ food insecurity.
00;07;08;28 - 00;07;43;17
Dr. Palakshappa
But me and my colleagues wanted to take a little different look at it and think about it from the family perspective. And although there's these studies looking at individual health care expenditures through thinking about the, evaluating the relationship between the whole family could sort of provide a better understanding of the financial implications of food insecurity for families overall, as well as could provide a little bit better understanding of how food insecurity interventions could potentially reduce overall health care costs.
00;07;44;01 - 00;08;01;29
Dr. Palakshappa
Because sort of any intervention that addressed food insecurity, sort of providing food, a lot of things have been focused on medically tailored meals or food prescription programs, families generally share those resources. It's not a sort of a simple one person gets it and the other person, other people in the household have to sort of just sit back and watch them get these resources.
00;08;01;29 - 00;08;10;15
Dr. Palakshappa
They tend to share it. And so I think this provides sort of a more nuanced idea of how an intervention could reduce the health care expenditure costs.
00;08;11;07 - 00;08;32;29
Alan Weil
You know, so this is a really interesting part of studying health care in general, is that we have a lot of programs that are individually focused, eligibility for Medicaid is an individual determination. And you can have people in a household, some of whom are on one program and some of whom are on have one insurance plan. Some of them have a different one.
00;08;33;15 - 00;08;51;25
Alan Weil
And if we study those all separately, we completely miss the dynamics here. So you've tried to break some of those barriers down. Let's talk about the major findings as a general matter. What did you find about the relationship between food insecurity and health care expenditures at the family level?
00;08;52;09 - 00;09;20;28
Dr. Palakshappa
Yes. So we looked at a national survey data looking at 14,000 or over 14,000 children and adults representing sort of over 6,000 distinct families and found that families that were food insecure in 2016 had 20% greater health care expenditures in 2017. And that totaled, that estimated to be about $2500 per family for the year.
00;09;21;11 - 00;09;42;23
Alan Weil
And the time horizon here is really important. You're looking at you're comparing families that were food insecure with similarly situated families that were not. And you're seeing this higher rate of spending, which gives you good reason. It's not a it's not an experiment here, but it gives you good reason to believe that there's a relationship between these two phenomena.
00;09;43;08 - 00;09;48;21
Alan Weil
Tell me a little bit about the subgroups that you looked at, you looked at, well, I'll just leave it at that.
00;09;48;24 - 00;10;06;11
Dr. Palakshappa
Yeah, great question. And again, so we were trying to again, this is not an experimental study, so we tried to look at the data a number of different ways to make sure, you know, our findings sort of held for across different subgroups, across different ways that we looked at the data. And so we looked at in a number of different ways.
00;10;06;12 - 00;10;50;27
Dr. Palakshappa
So first, we just looked at, you know, we looked primarily, our primary analysis is looking specifically at the total health care expenditures, but we also wanted to look at individual health care expenditure types. So inpatient visits, outpatient visits, medications, out-of-pocket costs, and other than out-of-pocket costs across the board, families that were food insecure in 2016 had higher individual health care expenditure types, and interesting, medications tended to be the highest one, which we're not really sure why, but, you know, it's one thing that we found no matter how we looked at the data and no matter which side we looked at. Another way we looked at it is we looked across sort of family characteristics.
00;10;50;27 - 00;11;10;24
Dr. Palakshappa
In the family characteristics we were able to get from the data that we had. So race and ethnicity of the primary respondent, the household income, the region of residence for the family. And similarly, no matter how you looked at the data, those families that were food insecure had higher subsequent health care expenditures.
00;11;11;15 - 00;11;48;28
Alan Weil
You also looked at health insurance, and I think that's a really interesting one because we tend to think of, again, poor people more likely to be food insecure, concentrated in Medicaid. But when it's one out of ten families, you have folks in all kinds of insurance. I want to hear about some of the differences across insurance status, but we'll have that conversation after we take a short break.
00;11;48;28 - 00;12;13;20
Alan Weil
And we're back. I'm speaking with Deepak Palakshappa about the relationship between food insecurity and family health care expenditures. Before the break, we got to the top line findings here about the relationship, but we've started discussing some of the subgroup analyses. And one of the interesting dimensions had to do with the type of health insurance people have. So let's pick up right there.
00;12;13;21 - 00;12;23;03
Alan Weil
Tell us a little bit about how you looked at health insurance coverage and what you found about the relationship between these two phenomena, depending on people, the type of coverage they had?
00;12;23;13 - 00;13;07;13
Dr. Palakshappa
Yeah. So one of the sort of sort of interesting things and I guess exciting things is that a lot of health insurers, both public and private, are beginning to invest in interventions or programs to address their enrollees lack of access to food. They're trying a number of different interventions. And so we specifically wanted to look at that sort of health insurance type for families and the way we were able the only way we were able to do it based on the data that we had is that we had to categorize families as having all private insurance, all public insurance or mixed insurance, which included family members having private, public or uninsured.
00;13;07;13 - 00;13;46;16
Dr. Palakshappa
And again, just like sort of our main findings, those families that reported being food insecure had higher health care expenditures, no matter what the sort of family insurance category was. And I think why that becomes particularly important from a policy standpoint is that you have these you have insurance companies that are beginning to invest in interventions to address food insecurity and other unmet social needs as a way to sort of improve health, mitigate avoidable utilization, reduce health care expenditures and in our findings, support sort of that promise that families that are on the same insurance type because they'll share resources.
00;13;47;02 - 00;14;10;27
Dr. Palakshappa
Even if you target one member of the family, they're likely all potentially going to benefit through better health, maybe reduce health care costs. I think it becomes a little bit more complicated for the one in five families that we found that had mixed insurance. You can imagine that a single carrier is going to invest in an intervention for a particular person in the family.
00;14;11;13 - 00;14;35;08
Dr. Palakshappa
But those resources are going to go to other members of the family. So that that carrier, that insurer, may not see the full benefits that they had sort of hoped to reach. And that could potentially lead to less investment in these kind of interventions. I don't think that's really just an academic issue per se, because, as I mentioned, we found one in five families.
00;14;35;08 - 00;15;07;10
Dr. Palakshappa
So this is going to likely be an issue moving forward from a policy level. And I would even say that it's, one in five families is probably an underestimate. There's probably more have mixed insurance. And actually several studies published in Health Affairs over the last couple of years specifically have looked at how working families, low middle income families, are starting to move, have their children get public insurance, Medicaid and SCHIP, while the parents stay on employer sponsored health insurance because of the higher out-of-pocket costs.
00;15;08;04 - 00;15;16;08
Dr. Palakshappa
So you can see this potentially that these investments, while they are exciting, they could lead to some potential problems moving forward.
00;15;16;20 - 00;15;42;02
Alan Weil
Yeah, you're providing us with a really clear example of the limitations of sort of an individual enrollee by enrollee approach to addressing the so-called social determinants of health, that these are family and community and societal challenges that one insurance company, if it's just trying to make an economic decision, will we save the money on the back, on health costs by making this investment there?
00;15;42;06 - 00;16;02;10
Alan Weil
They're missing a lot of the cost. And in this instance, it looks like they may be missing some of the benefit. And that's going to skew their calculations, might skew what they're willing to pay for. Now, you're a practicing physician, and you mentioned earlier this isn't just academic. I think that's right. But this whole topic isn't just academic to you.
00;16;02;10 - 00;16;07;16
Alan Weil
Can you give us a little sense of how you see these issues play out in your clinical practice?
00;16;08;04 - 00;16;33;05
Dr. Palakshappa
Yeah. So, I mean, I would say overall, I'm really encouraged by sort of the growing interest in investment in thinking about how do we assist patients who lack access to food or have these other unmet social needs. I'm a practicing, as you mentioned, I'm a practicing general internist and pediatrician. I got interested in the topic of food insecurity because of my patients.
00;16;33;15 - 00;16;58;13
Dr. Palakshappa
I still distinctly remember as a trainee when one of my patients told me that she couldn't afford both her medications and food. And I just sort of didn't have anything to offer. I didn't really know what to say. And I'm hoping with these sort of growing investments in sort of the increasing interest in this, that we are going to be able to have more interventions to assist patients right there at the point of care.
00;16;59;24 - 00;17;19;25
Dr. Palakshappa
But I think what this paper helped me sort of think more broadly about is thinking about it from more of a family standpoint. You know, as physicians, we often get sort of singularly focused on the patient or the problem that's that we're sort of dealing with in that clinic visit. But, you know, people aren't sort of just islands amongst themselves.
00;17;19;25 - 00;17;49;08
Dr. Palakshappa
You know, they have family. They live in households. There's a lot going on. You know, it's hard for me to talk about, oh, you should increase your exercise or take this medication when, you know, they're worried about, can I feed my kids next week? And so I think this is a good reminder of those issues and to think more broadly about interventions around sort of individual patient visits and thinking about sort of how do you incorporate the family into those interventions.
00;17;50;13 - 00;18;22;28
Dr. Palakshappa
I also think it's helped me sort of think more importantly about how to advocate and support policies in particular that either reduce or eliminate food insecurity. So programs like the Supplemental Nutrition Assistance Program, the WIC program, and actually in the December issue of Health Affairs, there were several articles about many of the programs like the Earned Income Tax Credit, temporary assistance for needy families, that all have potential to lift people out of poverty, get them better access to food, and hopefully improve their health.
00;18;23;23 - 00;18;52;10
Alan Weil
Well, this is such a I have to say it's very gratifying to hear you talk about this issue this way. We certainly hope at Health Affairs that we can expand the horizons of thought and policy relevance to the world of health and medicine and help people like you see that there are policy approaches that can address the challenges in front of the patients that you're seeing.
00;18;52;21 - 00;19;19;01
Alan Weil
At the same time, it's really exciting that you bringing the lens that you have can improve our ability to make those policies the right ones, because you can look at them through the lens of practice and what will actually support your patients, not just what we think will work on a piece of paper. So this is sort of exactly why we're here.
00;19;19;01 - 00;19;42;17
Alan Weil
And I didn't know that I'd be reaching this point in conversation when we started, but I felt like this is sort of the best of what health services research is about. And it's great to be able to talk to you about that. Let me just ask as we finish up, if you have any sort of next thoughts in this topic, it's not the first work you've done on the subject.
00;19;42;17 - 00;19;47;08
Alan Weil
And so what questions are sort of on your mind that you hope you'll get to in subsequent work?
00;19;47;22 - 00;20;09;06
Dr. Palakshappa
A couple of different things. Ideas that I have sort of moving forward, and I was fortunate to work with some great colleagues on this paper that will continue to work on other things moving forward. But again, I think a big piece of this is from just an investment standpoint for health systems, health insurers, is showing that benefit on health outcomes.
00;20;09;28 - 00;20;31;21
Dr. Palakshappa
And I think that's where a big part of the field is moving to is sort of showing, yes, we do see improved health when we do these interventions. So that's a large part of what I'm really focusing on. I'm particularly interested in some of the internists and pediatrician around the family unit and how do we sort of think about sort of family benefits.
00;20;32;29 - 00;20;58;14
Dr. Palakshappa
I think that's particularly important for in pediatrics, where, you know, a lot of the national pediatric organizations have sort of encouraged and are recommending pediatricians to screen for these unmet social needs, like food insecurity. But they may not see that sort of short term benefit in, you know, when funders don't see immediate benefits, they often get a little bit concerned.
00;20;59;25 - 00;21;22;28
Dr. Palakshappa
And while certainly there's potentially long term benefits for children, there may be short term return on investment for their parents. If they get better access to resources again, something they can share with the whole household. So those are two sort of big, big topic areas that I'm thinking about as well as some other things, but yes, there's lots of work to be done and I would encourage anybody to help move this field forward.
00;21;23;17 - 00;21;40;18
Alan Weil
Well, that's great. Thank you so much for sharing your work and your enthusiasm for the topic, for your engagement with your patients and looking at them in family context. That's a refreshing and important perspective. Dr. Palakshappa, thank you for being my guest on A Health Podyssey.
00;21;40;22 - 00;21;49;09
Dr. Palakshappa
Well, thank you so much for having me. And again, a big thank you to my colleagues and coauthors for this for helping move this project forward.