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Each week, Health Affairs' Rob Lott 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.
Hello and welcome to Health Affairs four part podcast miniseries on food, nutrition and health. I'm Jessica Bylander, a deputy editor at Health Affairs. We're releasing four episodes of this miniseries on Wednesdays leading up to and continuing with the publication of our April 2025 theme issue on food, nutrition and health. In today's episode, we're focusing on the topic of food support programs and their impacts on very young children. I'm so pleased to be here with Doctor.
Jessica Bylander:Diane Whitmore Schonsenbach, who is an economist and the Margaret Walker Alexander Professor of Human Development and Social Policy at Northwestern University. Doctor. Schonsenbach is the coauthor with Doctor. Betsy Thorne of a health policy brief we published on this topic in 2019. Welcome, Doctor.
Jessica Bylander:Schonzenbach.
Diane Schanzenbach:Thanks for having me.
Jessica Bylander:So first, to set the stage, what do we know generally about the health impacts of food and nutrition insecurity on very young children, which I think you define as zero, age zero to four.
Diane Schanzenbach:That's right. Those ages zero to four are particularly sensitive times where if you don't have access to adequate nutrition, it has lifetime impacts on you. Right? So that period of time, of course, you know, your brain's growing, your body's growing at a very rapid rate. And it's really important that we protect kids from any sort of negative shocks, you know, whether their parents lose their jobs or there's a recession or just for whatever reason, there's not enough food in the house that can not only harm kids in the short run, but then there's increasing evidence that it hurts them in the long run as well.
Jessica Bylander:Yeah. And just thinking about health equity and what we know, do do we see differences in the experiences of food and nutrition insecurity by certain demographic factors?
Diane Schanzenbach:First, I want to say that households with children are more likely to experience food insecurity. So compared to everyone else, kids are more likely to be exposed to this. And the second is the racial and ethnic gaps are large. So in general, food insecurity rates for black families and for Hispanic families are about twice the level as they are among white families. So the the disparities are quite large.
Jessica Bylander:And in your health policy brief, you you write about a couple of major federal food support programs that young children access. So so what are these programs?
Diane Schanzenbach:So the big two are SNAP, the Supplemental Nutrition Assistance Program, and WIC, the Special Supplemental Nutrition Program for Women, Infants and Children. So SNAP and WIC are doing the lion's share of the work here. And they're different in some important ways. And so let's unpack that for a minute. So first, is a large program.
Diane Schanzenbach:It's not just for kids. It's not just for families and kids. Something like fourteen percent of people in The United States participate in SNAP. On SNAP, you get a card that you can take to the grocery store or farmers markets or other places, and it'll debit off of your your benefits. And so you can choose most foods that are available at grocery stores.
Diane Schanzenbach:There are some exceptions. And you face prices and, you know, decide, you know, how you want to allocate your your resources. Most families also have cash income that they bring to that. So the first letter in SNAP is for supplemental, and right? It means that most families, you know, have to bring multiple types of resources to the grocery store.
Diane Schanzenbach:Now, WIC, on the other hand, is a much more narrow program that's right there in the name of it. Right? Women, infants and children. It impacts a large number of children in this age range, especially infants. So you might remember or certainly anybody who's had an infant remembers how expensive infant formula can be.
Diane Schanzenbach:Oh, yes. It provides infant formula for babies who are either not fully breastfeeding or are only partially breastfeeding or not breastfeeding at all during that first year of life. After you turn one, you get vouchers for very specific goods that are known to be very important nutritionally, especially for these young children. So think about, you know, gallons of milk or orange juice or, you know, peanut butter, you know, other sources of protein, things like that. And so something that's interesting about it is these are vouchers not for dollar amounts, but for actual, you know, containers of formula or gallons of milk, etcetera.
Diane Schanzenbach:And so between these two programs, that's sort of our front line of defense against food insecurity for the youngest children in The United States.
Jessica Bylander:Yeah. And do a lot of families use both or, you know, is one more I don't know if popular is the word, but one more utilized than the other?
Diane Schanzenbach:More families with young children are eligible for WIC just because of the way that it's set up. It's a little more generous in terms of the income cutoffs that you're allowed to have. And something like 80% of people who are eligible for, especially those infant formula benefits, participate in the program. I want to say that something like half of all infants in The United States get WIC in that first year of life. So it's a very, very large program and just extremely important for that first year of life when it would just be unconscionable to let a child go hungry.
Diane Schanzenbach:Well, I guess it's always unconscionable to let a child go hungry, but especially with the brain development in that first year. So then, you know, what we see is after that infant formula benefit ceases, participation in WIC falls off quite substantially, such that by age four, only about thirty percent of those who are eligible for WIC are participating in it. In the brief that we produced for health affairs a few years ago, we showed that actually there are more three year olds on SNAP than there are on WIC. That's not true for zero, you know, for newborns. But because of just the way that this evolves over time, lots of families don't continue to use the benefits as their children age.
Jessica Bylander:And in the brief, it seemed like, you know, it's hard to get a handle on exactly how many kids are using both programs or like what percent. So I think you you all estimated at the time that twenty nine percent of children, zero to four participated in SNAP and also twenty nine percent in WIC. And that was, I think, 2016 number. So is there a sense of of whether the numbers have remained pretty stable or have they changed, especially, you know, with the pandemic and everything going on?
Diane Schanzenbach:Exactly. Exactly. So we've seen a couple of trends since then. And you're right. Our brief was written a couple of years ago and it's just hard to get the data to study this in all of the ways that we'd like to.
Diane Schanzenbach:So, you know, apologies for those limitations. So we've seen a decline in the number of children who are eligible for WIC, and that seems to be primarily driven by declines in the population in this age. We've seen a decline in newborns, etc, whereas conditional on being eligible share of the population that participates has been pretty stable over the last five to eight or so years. On the other hand, SNAP increased substantially during the pandemic. We made the benefits more generous in some ways and participation has gone up about 15% since the pandemic.
Diane Schanzenbach:Now, some of that was also because were before the pandemic, we were at a pretty good economic place. And, you know, then, of course, the bottom fell out and lots of families lost their jobs. And, you know, it takes a while to you to get back on your feet after that. But, you know, I think we've seen, you know, overall SNAP participation go up. WIC, you know, has gone down a little bit, but that seems to be driven primarily by the number of people in the population that are of that age.
Diane Schanzenbach:Now, at the same time, I think I want to mention that food insecurity has also gone up since we wrote this brief. There was, you know, it went down for a couple more years, you know, and then we saw some ups and downs during the pandemic. But then, of course, more recently, in part due to food price inflation, other factors as well. We've seen food insecurity go up a little bit.
Jessica Bylander:Okay. Well, yeah. Yeah, I guess that's I mean, I'm sure something concerning and something to watch in terms of of participation and and the impacts. I am curious sort of what the evidence shows about how effective SNAP and WIC are for very young children, sort of like what we know and what don't we know.
Diane Schanzenbach:So some of the, I guess, most exciting evidence, if I can call it that, comes from a paper that I wrote with Hilary Hoynes and Doug Almond a few years ago where we used variation in the original introduction of SNAP. At the time, it was called the Food Stamp Program, and it was launched as part of the war on poverty in the 1960s and the 1970s. And not to bore the listeners, but because of the way that it was rolled out, we can do a real tight study of what happens when you live in the same state, you have access to SNAP because of the county that you live in, but your neighbors don't. And so we can do some comparisons. So we find a couple of things.
Diane Schanzenbach:The first is that incidence of low birth weight goes down when moms have access to SNAP benefits when they're expectant mothers, and birth weights go up. That was particularly the case for Black families. And so as a result, the SNAP benefits improve outcomes for everybody, but disproportionately for black families. Looking at the sixties and seventies, the Hispanic population was much smaller at the time, so we couldn't look at them. So then we've been able to follow people who were children when food stamps were originally introduced.
Diane Schanzenbach:And we can look to see what happens if you had access to the program, let's say between the time of conception through age five, on your long term outcomes. What we find is twofold. The first is health is improved substantially. So in particular, in that we measure what's called metabolic syndrome or markers of metabolic syndrome. So we find that if you have access to adequate nutrition because of SNAP in early life, you grow up to be less likely to be obese, less likely to have heart disease, diabetes, etc.
Diane Schanzenbach:Also, there's evidence that just asking adults, you know, how is your health? Are you excellent, good, fair, poor? They're more likely to report that they're in good health in adulthood because of what happened to them in early life. And we also find that economic outcomes get better for these children. They're more likely to graduate from high school and particularly among women, we find that they're less likely to be in poverty, themselves less likely to be on food stamps in adulthood and earning more and more likely to be employed, etc.
Diane Schanzenbach:Now all of this, I think, comes back to where we started, which is this is a particularly sensitive time. Making sure that kids have adequate nutrition during this time period impacts both their physical development of, all sorts of body systems and also their brain development. And that pays dividends over a lifetime. Based on that, you know, my real concern is we need to make sure that no child in this developmental period experiences food hardship. Even if we're in a recession, you know, even if, you know, all sorts of negative shocks, you know, are happening around them, as a society, it's really important to protect especially the youngest, most vulnerable kids.
Jessica Bylander:Yeah. I'm I'm just struck by, you know, how hard it would be to concentrate in school and, you know, to to achieve your academic goals if you're hungry or if you're just not getting the right food. So that really resonates to me, especially as a parent. I'm curious, since you published the brief in 2019, what, if anything, has changed in the evidence base? You know, have any exciting new findings been released, new data sources, anything like that?
Diane Schanzenbach:Of course, there was that pandemic that's happened between here and there. And one of the most exciting pieces of evidence to come out of the pandemic was the impact of the fully refundable child tax credit. So again, to walk out for just a quick second, in normal times, the child tax credit primarily goes to families that are employed. And what that means is the lowest income children either don't get any child tax credit or don't get the full amount. Now during the pandemic, that changed.
Diane Schanzenbach:Everyone got the child tax credit, and in fact, they boosted the amount of the benefits for everyone and even more for the youngest children. The results, you know, I think are very impressive. We reduced child poverty by 50%. There's evidence that food insecurity dropped, that people spent this money in ways that invested in kids, etcetera, etcetera. Unfortunately, we rolled back that fully refundable child tax credit after this time period.
Diane Schanzenbach:And I think that that policy is ready for prime time. Until we get to that, we also want to think about how SNAP and how WIC stepped up during the pandemic. And then how to continue to make sure that they're as fortified as possible so that kids aren't falling through the cracks.
Jessica Bylander:Yeah. Yeah. Thinking about sort of the recent policy landscape and some of the initiatives, it does seem like a lot was driven by the pandemic. So I think you've mentioned a few of the pandemic related changes, child tax credit, increasing SNAP benefits. So I guess, mean, first of all, has everything during the pandemic, all of those changes been rolled back at this point and sort of what do you think about in terms of policy initiatives, what's needed or sort of what currently is being implemented that that sort of has the best chance of of improving health for these very young children.
Diane Schanzenbach:One of the policies that has not been rolled back was that during the pandemic, the Department of Agriculture revamped the Thrifty Food Plan, which is the amount of money that SNAP benefits are based on. The Thrifty Food Plan had gotten really out of date. It had only really been updated for inflation over the last, you know, many decades and USDA had to do, you know, increasingly, you know, sort of gymnastics to try to make to try to show that you could make ends meet and eat a healthy diet on the old Thrifty Food Plan. And so USDA, after being instructed to do so by Congress, tried to find a new way. So the upshot of this is that there was about a 20% increase in SNAP benefits across the board.
Diane Schanzenbach:Now, this is particularly important for young kids. You might remember from the brief that about half of young children who are on SNAP live in households with incomes less than 50% of the poverty line. These are some of the lowest income and most vulnerable children. And this wonky change in the Thrifty Food Plan that increased benefits by 20% means that all families on SNAP, but particularly those families, have more resources to spend. You know, their benefits can last longer in the month.
Diane Schanzenbach:They can get, you know, more nutritious foods, a more, you know, more variety of foods, etcetera. Now I'm concerned that we're going to roll that back. I think that that will be a shame. Right? Reducing SNAP benefits will come at a cost of food insecurity, you know, protection among the of the vulnerable, etcetera.
Jessica Bylander:Are there where are the kind of the biggest policy gaps? I think in the brief, you talk about sort of there's like an age range where it's a little bit of a no man's land between between these like policy programs that are available. Can you talk a bit about the gaps?
Diane Schanzenbach:Everybody knows about school meals. And once you get into kindergarten, you know, in many places, there's universal free meals and, you know, free and reduced price lunch, etcetera. But WIC stops at age four and a lot of kids don't start kindergarten until age five. And so there's this year or so that is just a no man's land. Sure, they're still eligible for SNAP, but these other policies that prop up families incomes and make sure that no kids are falling through the cracks, There's just this cavern for those between age four and five.
Diane Schanzenbach:The other point, which I'll reiterate, is how important it is for us to try to understand why do families drop out of WIC when they've got a one year old or a two year old or a three year old and find ways to encourage participation among those ages. Again, sort of coming back to just the tremendous importance of making sure that we're protecting kids in these age ranges, that we're developing their brains and their bodies and that they've got enough healthy food to eat.
Jessica Bylander:Well, thank you so much, Doctor. Shonson Bach, for joining us. I mean, this conversation has been so interesting and like obviously so timely with, you know, as as we know the high cost of groceries and everyone sort of feeling it economically. So I really thank you for unpacking your brief and sort of updating us on what's going on more recently.
Diane Schanzenbach:Thanks so much for having me.
Jessica Bylander:Great. So we'll put a link to the health policy brief on this topic in the show notes. To our listeners, be sure to visit Health Affairs to read the April issue on food, nutrition and health and listen to the other episodes in this podcast series. Thank you.