Subscribe
Share
Share
Embed
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.
Welcome to A Health Podyssey. I'm your host, Rob Lott. The Special Supplemental Nutrition Program for Women, Infants, and Children, better known as WIC, is a nutrition program that helps low income, pregnant, and postpartum women, infants, and children under age five who are at nutritional risk. According to the USDA, which oversees WIC, the program serves about 6,900,000 participants each month, including an estimated forty one percent of all infants in The United States. Federal program costs for WIC totaled $7,700,000,000 in fiscal year twenty twenty one.
Rob Lott:Now, although WIC is federally funded, it's administered by the states, and states have some flexibility to shape policies around eligibility determinations and enrollment. And during the COVID-nineteen pandemic, that flexibility was expanded. Naturally, different states made different decisions about what to do with that flexibility, creating variation that may have had differing effects on participation rates, as well as potentially on health outcomes. So what can we learn from that variation? That's the subject of our podcast today.
Rob Lott:I'm here with Doctor. Emily Dore, an assistant professor of public health and community medicine at Tufts University School of Medicine. With colleagues, she has an article in the September issue of Health Affairs. Its title is also one of its main findings, quote, WIC benefits issued remotely increased participation, especially in states with online benefits distribution, 2017 to 2021. Doctor.
Rob Lott:Emily Dore, welcome to A Health Podyssey.
Emily Dore:Thanks so much for having me.
Rob Lott:Well, why don't we just, dive right in? And I thought maybe we could start with some background, and hoping maybe you can give us a sense of the relationship between WIC participation and health. What do we know?
Emily Dore:Yes. So WIC is an incredibly important social safety net program, especially for maternal and child health for the reasons that you were saying before, you know, all the nutrition benefits. And so probably the most proximal outcome that we can think about is diet, and there's evidence that WIC is associated with improved diet quality as well as decreased food insecurity. There's also health impacts that are a little bit more downstream. So improved maternal health, things like lower rates of preeclampsia and increased rates of gaining enough weight during pregnancy to have a healthy pregnancy.
Emily Dore:Also, lower rates of preterm birth, low birth weight, as well as, more healthcare utilization. So children are more likely to get their preventative healthcare visits in, get the recommended vaccines, as well as the mothers are more likely to get more prenatal health care visits. And these studies are generally comparing, you know, WIC participants to people who are eligible for WIC but aren't participating, so trying to get the control and treated groups as similar as possible. So, yeah, WIC, there's definitely a lot of evidence that WIC is beneficial for health.
Rob Lott:Got it. Okay. Well, I'm glad you mentioned that sort of discrepancy between people who are eligible but might not be enrolled. Obviously, that's a useful factor when we're doing research about the impact of the program. But it's also sort of a challenge that we face in general when it comes to public sector programs, safety net programs in particular.
Rob Lott:And I'm wondering if you can say a little bit about the sort of proportion of those who are eligible for WIC compared to those who are actually enrolled. And then maybe put it in the context of the COVID nineteen pandemic and how the pandemic kind of changed potentially policymakers' thinking about that gap.
Emily Dore:Sure. Yeah. So this is a really important question. And one of the reasons we wanted to conduct this research is because participation rates for WIC are generally relatively low. Only about 50% of people who are eligible actually are participating in the program, and this is compared to something like the Supplemental Nutrition Assistance Program or SNAP.
Emily Dore:About 80% of those who are eligible actually participate in this program. So, yeah, WIC participation rates are relatively low, and that varies by participation category. So WIC tends to break out, participation rates by things like children, infants, and women. And so infants have the highest participation rates with about 80% of those eligible actually participating, whereas children who are four years old have the lowest rates at about 25%. And relative relevant, excuse me, for this study, those participation rates really vary across state, as you were sort of mentioning in the intro.
Rob Lott:Okay. So let's put that in the context of COVID.
Emily Dore:Sure. Yeah. So in terms of participation rates during COVID, you know, WIC coverage had actually been decreasing before COVID and continued the coverage rates decreased, through, I think, 2021. And that, of course, eligibility was increasing during COVID because of the unemployment, crisis during COVID. The coverage rate has actually started increasing in the past couple of years.
Emily Dore:So in terms of your question about how maybe this changed how policymakers were thinking about WIC and coverage rates, you know, I don't I don't really know if it changed anybody's ideas or the way they were thinking. Before the pandemic, there were moves to sort of modernize WIC. They had there was a federal mandate for states to switch from paper vouchers, so, you know, bringing in physical pieces of paper to the grocery stores for WIC participants to purchase their groceries. So the government the federal government wanted states to switch from those paper vouchers to electronic benefit transfer cards, EBT cards, by 2020. So not all states were able to do that, but that was sort of the goal to switch.
Emily Dore:So policymakers were thinking before the pandemic about ways to modernize or increase access, decrease stigma around WIC before the pandemic. But then as I think we'll talk about in the context of this study, there were a lot of changes to the WIC program, including, of course, increasing remote services. And I don't and now there have been a couple of pieces of legislation introduced in the House and the Senate to continue offering these remote services. Whether these would have been, you know, introduced by policymakers now without the pandemic, I'm not sure. Maybe it did increase the speed at which these services were considered.
Emily Dore:But, I guess I can't speak exactly. So was it the pandemic that made them think this way or not? But things are
Rob Lott:happening. Yes. A counterfactual we can never truly know for sure. But take us back to sort of the height of that pandemic. In my introduction, I said that flexibility was expanded.
Rob Lott:Can you say just briefly what happened? There was essentially a waiver that allowed states to, sort of adjust their policies in a way that maybe they couldn't have before. Is that a fair description?
Emily Dore:Yes, exactly.
Rob Lott:Okay, great. Well, then let's jump right into your paper. And you looked specifically at the impact of sort of five different policy changes in response to this flexibility. And, why don't we start there? What were those policy changes?
Emily Dore:Sure. So, yes, and to sort of answer what you were asking just now too. So under the Families First Coronavirus Response Act of 2020, the USDA provided waivers to states and local WIC agencies to make some policy changes to their program, to increase access to the program, both because there was this increased need as well as, of course, the public health safety risk of things like in person appointments. So the USDA allowed states to apply for these waivers and then implement these waivers. And fortunately, the USDA did survey these states in March and April 2021 to see which states implemented them, when, how it went, how people sort of felt about these waivers.
Emily Dore:And I read this report a couple of I think it came out a couple years ago and was really struck by, wow, this is a wonderful opportunity for, you know, a natural experiment to understand how these waivers or policy changes is, I think, how we refer to them in the paper, but policy changes impacted participation and maybe some of these downstream health outcomes too. So generally, the waivers decreased administrative burdens and or increased sort of incentives to participate in the program. So we, as you mentioned, wanted to look at five even though there were multiple, I forget now, 15 to 20 different waivers that we could have looked at. We chose five that we thought would be more likely to impact participation rates. So the first is this remote benefit issuance, which usually participants need to come in person to a WIC office, especially for that first appointment to be, you know, assessed for nutrition risk, to fill out forms to determine eligibility, and then to actually receive, you know, that paper voucher or that EBT card.
Emily Dore:So this waiver allowed states to provide benefits remotely. So most, I think, most states mailed the EBT cards or the paper vouchers, whichever they were using. So that really decreased the need for participants to come into the office, which, of course, is good from the public health standpoint, but also, there's been a lot of qualitative research about how that's just really burdensome for people to make the appointment, find the transportation, etcetera, to come to those program to come to those meetings. The second voucher is the extended certification voucher. So generally for these programs, any a lot of the safety net programs, people are certified as eligible for a specific period of time.
Emily Dore:That varies by participation group and by state. But this specific waiver, increased that certification period by ninety days for children specifically. So that cut down on the need, again, of filling out a bunch of paperwork to prove that you're eligible. It postponed it at least for ninety days. The third waiver is the medical documentation waiver, and this is for, infants who need a particular type of formula that's not generally covered by WIC, and so they need to get medical documentation to show that they're actually in need of this formula to be able to purchase it.
Emily Dore:And so this waiver waived that need to get that documentation. They would just be able to buy that specific formula or purchase it. The fourth waiver was separation of duties. So generally, more than one WIC staff member would need to, certify and approve the a participant to be able to participate in WIC. And so this waiver allowed just one staff participant to sort of streamline that process of approving somebody for benefits.
Emily Dore:And the fifth one was a food substitution waiver. So, you know, WIC purchased specific types of foods, or you're allowed to purchase specific types of food using WIC. And, you know, that can be really specific, like only 1% milk or, you know, this size bread or 12 eggs, not 18 eggs. So it can be really specific, and this waiver increased flexibility around the types of food that you could get. So if 1% wasn't available, you could get whole milk.
Emily Dore:And this was really important, especially in the COVID time, but I think it's important generally to have this flexibility. But because of supply chain issues, it was a big hurdle for participants to find WIC approved food. So those were the five waivers.
Rob Lott:Okay. Five really interesting waivers. And I imagine sort of each states were making their own decisions based on the advice of their local agencies, the feedback they were getting, maybe what the different, you know, administrators were interested in. And so suddenly you have what you described as like a really, you know, nice natural experiment, different states doing different things. And, your study looked at that.
Rob Lott:And, why don't you tell us what you found?
Emily Dore:Yeah. So we looked at the effect of these five policies on four different participation groups. So total, lumping everybody together, then women, then infants, so zero to twelve months, and then children one to four years old. And we found that the remote benefit issuance, so that first waiver I was talking about, increased participation across all groups except for the infant group. You know, the infant group coefficient was positive but not statistically significant.
Emily Dore:And we then stratified the states by whether they issued benefits online or offline, which means, you know, you could still have that remote benefit issuance waiver, but people were still having to actually come to the office to get their cards generally. So we found that the effect of remote benefit issuance was really, more meaningful in online states. We also found the food substitution waiver was generally positive for all participation categories. It wasn't statistically significant, but that was definitely a trend. We then created an index of policy changes to capture the number of policy changes each state had implemented in each month and found that women's participation increased in states with more policy changes in place.
Rob Lott:Got it. So, obviously, I guess this goes without saying, but it's not like states had to choose one or the other. They could have kind of stacked them on top of each other. And I guess you're saying that the more kind of creative mixing and matching that the states did, the more impactful it might have been at least among women. Is that right?
Emily Dore:Yes, exactly.
Rob Lott:Okay. Well, so, and then just to kind of revisit, zeroed in specifically on sort of the issuing of benefits remotely as maybe having the greatest impact. And I'm curious if you can reflect on that a little bit. Is there something sort of unique to this COVID nineteen, you know, era where people, you know, really didn't wanna go out and go to appointments and, you know, be in close contact with others? Is that really what was going on there?
Rob Lott:Or is there maybe something more broad or generalizable about that intervention that might be of note when it comes to thinking about safety net benefits and how they're administered?
Emily Dore:I think, you know, it is hard, of course, to separate this totally from the COVID-nineteen pandemic. But I think, yeah, this has been an issue that's been identified by a lot of different qualitative studies especially, but also studies of other programs where any kind of decreasing of administrative burdens and increasing access to a program through something like a remote benefit issuance is going to increase participation whether or not it's during the pandemic or not. This is identified really as a barrier, you know, being able to get to appointments because it's difficult to take time off of work. You know, WIC offices are open during nine to five work hours generally. So you have to take time off of work.
Emily Dore:You have to find childcare generally. You have to find transportation to get to these appointments. So it can be really difficult to actually make these appointments and get there whether or not there's a global pandemic going on or not. And so this is this is definitely an issue. So I was not really surprised to see that this had the most impactful effect on participation rates.
Emily Dore:And in term you know, again, for the food substitutions, I was kinda like, know, there was this positive relationship that wasn't statistically significant. And I think this was especially impactful during COVID because there was a supply chain issue. But, again, this is another issue that's been identified even outside of COVID that it can be really difficult to find the WIC approved foods, especially if people are going to more, you know, corner stores instead of large grocery stores. So this might have actually maybe we would have found more of an effect outside of COVID when there wasn't such a supply chain issue going on. So I think that's something that should definitely still be considered.
Emily Dore:There might have been more confusion even going on during COVID-nineteen. This wasn't really a long follow-up period. You know, we looked at the changes in 2020 and participation rates sort of in real time until the beginning of 2021. So I wonder if we had a longer follow-up period if we would have found some more, more effects on participation rates because there was so much going on during the pandemic and then getting all this new information out. You know, I think in some ways, yes, this is a pandemic story, but maybe that we would have seen even larger effects outside of the pandemic.
Rob Lott:I'm curious if you can say a little bit about sort of what policymakers might take away from this research. Is there a world where based on this, you know, states kind of universally implement, you know, remote, benefits? Or is there something else that you might expect that, you know, a a state agency administrator or a state legislator to kind of read your paper and kind of set them, to work in terms of making potential long term policy changes?
Emily Dore:Yeah. Yeah. Well, what I hope policymakers get from this paper is just the general idea that, you know, reducing barriers or reducing these administrative burdens to social safety net programs can have this meaningful impact on participation rates, especially for a program like WIC that has shown these beneficial health effects and has low coverage rates. But I do wanna mention, you know, a lot of people do find benefits in the in person appointment, so I know that there should be this balance between reaching more people but keeping the integrity of the program. But, you know, through, again, qualitative studies and the USDA report, it did seem like a lot of participants and staff were happy in general with the remote benefit issuance waiver.
Emily Dore:So, yes, I hope that policymakers can take that away from the paper. And as I think I mentioned earlier, you know, there are these two acts, one in the house and one in the senate, the modern WIC Act and the twenty first century WIC Act that are looking to make these remote services and remote benefit issuance and appointments, more permanent. And so I don't think our paper has influenced that because it isn't out yet, but maybe, this can bolster, you know, arguments for in support of these types of policies. And I do want to just say that I think it's really relevant in this period as the government the federal government is adding more administrative burdens to other safety net programs like SNAP and Medicaid. You know, they're different sort of administrative burdens, but they're, our study is showing that decreasing these types of burdens can, you know, impact participation.
Emily Dore:Contribute to that that conversation.
Rob Lott:Doctor. Emily Dore, thank you so much for taking the time to chat with us today. I had a great time.
Emily Dore:Thank you.
Rob Lott:And to our listeners, you can check out Doctor. Dore's paper in the September issue of Health Affairs. If you enjoyed this episode, please leave a review, recommend it to a friend, and, of course, tune in next week. Thanks, everyone.