There was a debate in The New York Times yesterday over the "proper" use of SNAP (formerly "food stamp") funds. The basic question is whether use of food assistance dollars should be restricted so as to preclude unhealthful food choices: soda, fast food and so on.
As one might expect, "my" clan-health experts, nutritionists and public health practitioners -- whom some of you no doubt see as the food police -- generally advocate for such restricted use of SNAP. The basic argument is that the burden of obesity and chronic disease falls disproportionately on the socioeconomically disadvantaged who depend on SNAP (this is certainly true, and very well documented); and there is no legitimate basis to use tax dollars to propagate this problem. They are opposed, however, by similarly well-intentioned anti-hunger professionals and activists, who contend that those facing food insecurity should not be precluded from using food assistance to buy what they want to eat.
If we could walk the proverbial few steps in one another's moccasins (something we seem increasingly incapable of attempting in our polarized society, more's the pity), we might acknowledge that there are legitimate arguments on both sides of this divide. We might also acknowledge that a third option might be nice.
There is one.
This debate is really over whether, and how, to wield a stick. Restricting food choices -- however good the intentions -- is a stick. Justified or not, it is rather heavy-handed. Personalizing it, I note that -- despite my well established, left-leaning, public-health-do-gooder bona fides -- I would not much care for some government agency telling me what foods I could or could not use my money to buy.
But we could sidestep this contentious debate altogether -- or at least defuse its inflammatory potential -- by making use of a carrot rather than a stick.
This debate is all about stick, when in fact, a nutritious food -- namely, the carrot -- is a far more palatable answer; an answer that provides a third option altogether.
We can characterize the current situation in very blunt terms. We, the taxpayers of the U.S., send $100 billion or so to the federal government each year to subsidize the USDAs SNAP program. I have no problem doing my part to make sure my neighbors don't go hungry, so I'm fine with this so far.
But as noted, the burdens of obesity, diabetes and virtually all chronic diseases fall especially hard on the SNAP population. With a truly overwhelming body of literature establishing diet as one of the master levers of medical destiny, we know that poor diet is on the very short list of explanations for this.
And thus, the situation really distills down to this: $100 billion of our taxes is used to help (relatively) poor people procure relatively poor food (thanks to the prevailing, if not entirely correct, inverse association between food cost and nutritional quality) -- so they can get to really poor health.
There is, of course, substantial overlap between the population relying on SNAP (which has grown tremendously during this period of economic hardship) and the population relying on Medicaid. And so, we are also on the hook for a vastly larger allocation of tax dollars to Medicaid to pay the costs associated with poor health, and propagated by poor food (among a short list of other major influences).
Again, I am okay with using some of my hard-earned dollars to make sure my neighbor can receive medical care he or she can't otherwise afford. But let's face it, in this scenario, everyone loses.
We, the taxpayers, lose; we are spending some of our heard-earned money to create a problem, and more of our heard-earned money to -- at best -- only partially fix it. We are billed twice, and aren't getting much reward for our pains.
The government loses because this inefficient allocation of funds siphons money away from other worthy causes: everything from education, to military preparedness, to the maintenance of our increasingly questionable infrastructure.
And the SNAP participants lose the most of all. They are the ones left to struggle with the combination of poverty and chronic disease.
While some restrictions on the use of SNAP dollars certainly makes sense to me, what makes far more sense is to incentivize the more nutritious food choice, from soup to nuts, so that more nutritious always means less expensive.
Using a system such as one I helped to develop (Nuval) that can objectively stratify the nutritional quality of any food or meal in a manner that correlates with health outcomes, foods could be put into quartiles (or quintiles, or deciles) of 'nutritiousness' by category (i.e., breads, cereals, lunch entree, dinner entree, etc.).
The purchasing power of 'food stamps' could then be linked to overall nutritional quality: The higher the nutritional quality, the lower the cost. Even a tiny improvement in health outcomes associated with this initiative could pay for it 10 times over (several of the world's leading health economists have collaborated with me on developing this concept, and concur -- although we all agree on the need to prove it). Everyone wins.
My group and I envision an application of this in both retail food outlets (supermarkets and restaurants) and schools. We call it FINGER TIPS. The name refers to putting empowering programming within reach, where the proverbial rubber hits the road (i.e., where food choices and purchases are made). It is also an acronym for Financial Incentives & Nutritional Guidance in Educational and Retail Settings: Taking It to the People in the Street.
We would like to see this tested with the SNAP population, and are working on doing so. But there is no reason for it to be restricted to such use. There is no reason why our private insurers couldn't form partnerships with our supermarkets under the following terms: We will underwrite a soup-to-nuts discount for (objectively measured) more nutritious food in every aisle of your store. You win because you can offer your shopper both nutrition guidance and a nice financial incentive for shopping with you. We win because if we keep our premiums fairly constant (note: ominously, insurance premiums are rising sharply at present) and reduce our costs, our profit margins go up.
And the shopper wins twice: They get reliable guidance to more nutritious food and a generous financial reward for choosing it. (For example: In any given food category, a dollar would be worth a dollar for any item in the bottom quartile of nutritional quality, but would stretch to $1.25 in the next quartile, $1.50 in the next and $2.00 in the top quartile.)
Admittedly, it will require more than a 'snap' of our finger tips to implement, test and validate this win-win-win approach. But it is eminently feasible; and sure beats beating one another with sticks in unending debate while getting nowhere.
Power -- and carrots -- to the people.
Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz