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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello and welcome to Health Affairs This Week. I'm your host, Jeff Beyers. We're recording on 03/24/2025. Before we begin, just as a heads up, we have a theme issue on food, nutrition, and health coming out in April. You may have noticed an extra episode in your podcast feed this week.
Jeff Byers:That's because we have a special four part podcast series leading up to and through the release of the issue. The first episode is on water insecurity. Check it and the other three episodes out, and watch for the issue's release in early April. Also, as a heads up, our next insider event is April 23 with Brady Post on-site neutral payments. As a quick plug, today, I'm joined by Seth Berkowitz from UNC School of Medicine.
Jeff Byers:Seth used to write an insider newsletter on social determinants of health. He wrote an article in the said theme issue on food nutrition health, will appear on Health Podicy to discuss that paper, and joins us today to talk about SNAP benefits. Seth, welcome back to the program.
Seth Berkowitz:Thanks so much for having me. I'm excited to be
Jeff Byers:Yeah, so today we're gonna talk about SNAP benefits. So Tennessee passed in the house that built up ban candy and soda purchases from SNAP benefits. So I wanted to ask you, as someone that looks at the intersection of food and health, what is the goal of such a ban, and is this controversial? You know, I was asking a leading question, why might this be controversial? But tell me it's controversial first before I ask that.
Seth Berkowitz:Yeah. I think I think this is I think this is controversial, so I think you're on on firm ground, saying that there's a bit of a controversy here.
Jeff Byers:Well, what's the goal, and why is it controversial then?
Seth Berkowitz:Yeah, so the goal I think is the non controversial part. So I think the goal is, I guess I should say the sort of ostensible goal or the stated goal, is to reduce the use of SNAP benefits on food products that are considered less healthy, and then therefore reduce the overall consumption of those products and improve health and and diet quality overall. So that that's sort of the idea that I think proponents, at least if taking the arguments at face value, are trying to lead you out. Two, I think it's controversial for two reasons. So people who are opposed to these kinds of proposals, think, will argue that one, it doesn't seem to actually be that effective in reducing consumption of these foods.
Seth Berkowitz:And two, that there might be some ulterior motives that might have to do with things like social control or a view of SNAP as charity such that the supposed benefactors can try to exert more control over how people using the program expend those resources and those kinds of things. I think that rubs a lot of people the wrong way. And so I think that's another sort of source of controversy here in addition to concerns about whether it actually is likely to achieve the stated impact.
Jeff Byers:Can you walk me through whether those kind of things do actually achieve those? Because it seems those are two different arguments, right, or two different ideas.
Seth Berkowitz:As best we know, programs like this are very unlikely to substantially improve diet quality, or, you know, reduce consumption of the prohibited items and those kinds of things. And the reason that I'm fairly confident saying that is this is one of the few areas of health policy that we actually have a randomized trial on. So there's a great randomized trial that I was not involved in conducting, I think was a really well done study done by Lisa Harnack's group in Minnesota. And so they took people currently on SNAP, they allocated them to various sort of permutations of benefit design, some of which included incentives for purchasing healthier foods, some of which removed the ability to purchase like sugar sweetened beverages and candy bars and those kinds of things, and then sort of a normal control condition. You know, they found, as other previous studies had found, that the incentive group actually worked well, so incentivizing healthier food purchases does lead to more purchase of those things, which was good.
Seth Berkowitz:The group that sort of banned the, or removed the ability to purchase certain foods considered unhealthy did not lead to changes in the consumption of those foods. You couldn't purchase them with the benefits, but people could still purchase them in other ways, the overall change, overall consumption went down. But I think importantly, the participation in the program for the people in group that received the ban on some of these things was almost 10% lower, 10 percentage points lower than the other groups. So not only did it not change actual consumption, which is what we think would lead to improvements in health for the people who continue to participate, but a lot of people, a lot more people kind of dropped out altogether, and so we're not getting benefits. So I think the likelihood that it will actually improve overall diet quality is low.
Seth Berkowitz:And I think there could well be unintended consequences where people either don't utilize the program or don't utilize as much of the program. And there could even be worse outcomes when you put on these sort of extra strictures and everything to the way the program's run.
Jeff Byers:Gotcha, gotcha. And just really quick, going back on the control aspect of like control of benefits, can you go a little bit more into why that might be controversial? Controversial? So we went into the consumption.
Seth Berkowitz:Yeah, so I think there a couple reasons. So I mean, in my mind, the essence of charity is that it's discretionary, right? So if you think of what a church or a private organization or something does, they kind of get to pick and choose who they may want to give programs to, what they want to focus on and those kinds of things. And that's private sector and I think seems fine. When you start talking about like an actual government program, something that people have a legal right to when they meet the qualifying conditions and those kinds of things, you're not really talking about charity anymore.
Seth Berkowitz:And I think sort of part of our overall institutions of income provision in The US, certainly since the 1996 welfare reform, have included a key role for SNAP as a way to support people's food budgets and people's income when, you know, they're in dire circumstances. You know, so adding on additional restrictions and other things to that to, you know, a group that are you're already not we're already not providing cash. You can't spend your SNAP benefits on everything. We already restrict the way that the food purchase is going to be spent. Famously in most states, can't purchase it on hot foods or things that are going to be consumed on-site.
Seth Berkowitz:It's only for groceries and food items that you're meant to take out of the store and then prepare at home and things like that. So there are already things there. So adding on additional restrictions, I think, strikes many people as sort of going against the purpose of the SNAP program to sort of provide this food assistance for people who are in dire straits. I'll say maybe just, I don't know, to me this is funny, I don't know if the listeners will think it's a funny anecdote, but sort of a funny anecdote, because these kinds of discussions come up all the time, and so I've had many conversations like these over the years, I was talking to someone who's in this space, a researcher in this space like I am, and this kind of thing came up, and I said, I don't think these restrictions are very worthwhile, and he said that, well, we should put these on, people won't use their SNAP benefits to buy sugar sweetened beverages or candy bars or those kinds of things. I said, well, we could have even more health benefits if we put those restrictions on what you can use dollars to buy, right?
Seth Berkowitz:Mean, if only one in six Americans use SNAP to buy their foods, but if 100% of Americans use dollars to buy their food, then we could have six times the benefit. And he said, well, SNAP is money from the government, so that's okay to put restrictions on, but I mean, putting restrictions on people's own money, that's not okay. I was like, my friend, I've got bad news for you about where dollars come from. They come from the government as well, and you know, we really think that this would just be beneficial for population health overall, but we're not doing it just to control a certain segment of the population, then I don't see any argument you could make about what the health benefits of restricting snap purchases would be that wouldn't also apply to how dollars might be restricted.
Jeff Byers:I'm going to throw out MAHA as far as like when looking at potential Make America Healthy Again goals, will such initiatives like this come more from states or federal policy?
Seth Berkowitz:Yeah, I mean, think there's broad recognition that diet and nutrition play a key role in health, that diet and nutrition in The US overall is not where it should be, and that's a key contributor to our relatively poor population health. I think a lot of people are getting behind the idea that we need to do something about that. I think there likely to be action at the federal level in that. It's been a priority that's been expressed. However, The US is a very federalized system, and so action from the state and the federal, sort of the national government can occur in parallel.
Seth Berkowitz:And I think to the extent that we're just sort of catching the zeitgeist here and saying, yeah, we really need to pay attention to these issues, then we may see it at the state level in addition to the federal level. Often these things are kind of complementary as well, right? I mean, one of the great things about our federal system is, you know, states are sort of laboratories in some sense where they can experiment with different policies that might, you know, get adopted and implemented nationally, and so I think we'll see a lot of that, you know, during this period as well, there'll probably be some federal initiatives, there'll probably be some state initiatives, those state initiatives might get taken national when they're successful and that kind of thing. So I think we'll see it coming from both levels.
Jeff Byers:Okay, great. So, speaking of that, we know when you're talking about the intersection of food and health, that food plays obviously a big role into the health of individuals. You know, The US life expectancy lags behind other countries. I think there's lot of evidence on that. Like, evidence and how does food play into that?
Seth Berkowitz:Yeah, so I think The US population health does lag, life expectancy lags. I think we develop chronic conditions earlier in life than many countries, and so the number of years lived with chronic conditions is more even in the setting of shorter life expectancy, and I think diet plays a key role in that. There's essentially no demographic or income group in The US that is really hitting dietary guidelines and has a very high quality diet. There's room for improvement in all areas. And I think that's the kind of thing that has effects over the life course.
Seth Berkowitz:It starts in maybe even in utero, but certainly at least in childhood, and continues throughout adulthood as well. And so I think there are a lot of ways that we could make America healthier overall by focusing on diet and nutrition. So there's a lot of ground to be covered there.
Jeff Byers:You know, it's interesting you talked about that restrictions on SNAP benefits doesn't seem to help consumption patterns that much, and you talked about incentives helping healthier consumption habits. You wrote a book recently. I can't remember the name of it. Please tell me it one more Yeah, called equal care. Equal care.
Jeff Byers:Was there anything in your book about those potential incentives to make diet better?
Seth Berkowitz:So one of the key arguments in the book and one of the key reasons we think that the American diet is less healthy than it should be, is that in general healthier foods just cost more than less healthy foods. And so when income is scarce, there's sort of this pressure or sort of incentive, a gradient pushing you towards less healthy, but more calorically dense foods. And so in the book overall, one of the things to talk about is the importance of income support programs for health, for getting income to people during times in their life like childhood or older age or periods of disability when they're not gonna get an income from their jobs in order to support people's ability to stay healthy during those periods because it's the accumulation of episodes of deprivation and things like that that lead to this poor health overall. And so things like nutrition incentives I think are very squarely in line with those kinds of things where our goal is to reach people at times in their life where it's really difficult for them to afford a healthy diet, have a program that makes that possible. And we would reap the benefits at a population level by making sure that people aren't falling into these situations where it's just really not that feasible for them to follow a healthy diet.
Jeff Byers:Yeah, so it's also interesting when you mentioned that healthier foods are expensive. And I think everyone listening to this probably knows that grocery costs are going up. What as a fine as we kind of close out this conversation and, you know, using the Tennessee soda and candy house ban, what can we see, especially in the light of increasing grocery costs, what might we see for food policy going forward to support making Americans healthy again, for lack of a better term?
Seth Berkowitz:Yeah, no. So I think it's a really important question. I think this is actually an instance where the current iteration of SNAP does very well, and people may not always appreciate it. So SNAP is indexed to the cost of a healthy diet. So the USDA calculates something called the Thrifty Food Plan, which is meant to be what the cost of sort of a minimum level of healthy diet would be.
Seth Berkowitz:It adjusts that benefit level on the basis of food price inflation. And so SNAP actually provides very good protection against some of these things. And so that's an element of the program that I think is really important, and we may want to continue. As probably many, I know you know this Jeff, many listeners may know as well, there was an important methodological improvement in the way that Thrifty Food Plan was calculated that went into effect in 2022 or 2023 that really sort of made it match better with what the cost of a healthy diet is right now. And that has been an important, again, sort of improvement in SNAP over the last few years.
Seth Berkowitz:There is always discussion about rolling those kinds of things back, and I think that would be another step back in population health for exactly the reason that you said, which is that right now SNAP is well designed to be able to buffer people against food price inflation, but if you sort of recalculated some of these things or removed that, then the value of the SNAP benefit would decline and it wouldn't be able to do as good a job at protecting people's food security and ability to afford a healthy diet.
Jeff Byers:Yeah, well, Seth Berkowitz, thank you again for joining us again on Health Affairs this week. Make sure the listeners, you check out the April theme issue of Health Affairs where Seth has a paper. Seth, are you able to share what the not breaking embargo, what it's on?
Seth Berkowitz:Yeah. So the the paper is about, a way to put together the concepts of income, food security, nutrition security, diet quality, and health. These are all kind of interrelated constructs that play a big role in understanding how these factors shape health, but they're a little bit related, they're a little bit distinct, they kind of can get jumbled up, so it's a way to try to provide a clear way to think about how these things fit together.
Jeff Byers:Yeah, well, listeners, become readers and check that out and listen to a health policy to hear Seth talk about that. And also, just interesting stuff as it's kind of an ever evolving nature with that intersection of health, diet, and income. So a lot of interesting stuff coming from that. And with that, again, Seth Berkowitz, thanks again for joining us today, and thanks to you, the listener, for joining us. If you enjoyed this episode, send it to The Fitness Influencer in your life.
Jeff Byers:Thanks, and we'll see you next week.