The program now known as SNAP (Supplemental Nutrition Assistance Program) and formerly known as food stamps has of late been much in the news, and consequently much on my mind. SNAP has been in the news because competing views of what it represents to us all figure prominently in the Farm Bill quagmire: because the harsh economy over recent years has landed fully one in seven American families on its rolls; because the sequester is bumping people off its rolls, with worrisome implications; and because the poverty that warrants such assistance is far more prevalent, if fleetingly so, than most of us realize.
SNAP has been much on my mind because in some ways, it seems to represent a program no one can love, while it could be a program everyone could love. Let's see if we can get there.
For starters, I think epidemiology should trump ideology. We can trust our opinions up to a point, but we should all embrace the need to verify. When the data point at something other than our preconceptions, we might at least entertain the possibility of changing our minds. If our polarized politics have turned the capacity to reconsider based on changing information from an open mind to waffling, we have certainly lost something precious.
Imagine the world of possibility if we would listen most closely to the opinions least like our own, and preserve civility and respect when disagreeing. Imagine the win-win opportunities in a world where middle paths, leading to common ground, were not routinely reviled and rejected. Imagine all the hard fixes that would be a snap in a world where the crackle of belligerence, and the pop to opposing corners did not prevail.
SNAP would be a great place to start. My personal ideology causes me to favor SNAP. The morality of my parents and the words of John Donne resonate with me. I believe that no one is an island. Sometimes, we all really do need somebody to lean on, and in that unity, there is strength. My convictions in this regard are fortified by an economy that has landed one in seven of us on the SNAP rolls. They are fortified further by knowing that while most of us don't live in poverty, fully about 50 percent of us do visit it at some point in our lives. The notion that programs of social support aide and abet the lazy and exploitative simply doesn't jibe with the massive shifts in the affected population over time. It seems unlikely that character traits come and go with the highs and lows of the stock market.
All of this argues persuasively about factors larger than individual fortitude or resolve, and unrelated to character. Sometimes there is ample good will, but just no way. Acknowledging that does not relieve us of the need to take responsibility for ourselves. Personal responsibility matters, too. But if great power brings great responsibility, it stands to reason that to exercise responsibility, we must be empowered. The choices any of us makes are subordinate to the choices -- in a given place, at a given time -- that any of us has.
And, frankly, the data make a pretty good case for SNAP, too -- and certainly argue against bumping struggling families off the rolls. The data in question are not about doing what's right -- they are about avoiding the boondoggle of penny-wise, pound-foolish economic policies.
But then again, I have listened to the alternative points of view. I cannot dismiss the legitimate opposition to frittering away public funds -- and there is a case that SNAP may do just that. If SNAP is intended to provide sustenance, then sustenance it should be. The use of SNAP dollars for soda and junk food may reasonably be questioned.
The questions for, and challenges to SNAP, expand when viewed from altitude. Poor dietary pattern is at the very top of the list of the leading causes of chronic disease and premature death in the United States, and increasingly, around the world. Poor diets and poor health are more prevalent among SNAP beneficiaries than the public at large. Sidestepping any relevant parsing of all the reasons why for the moment, we might simply acknowledge that we -- the American taxpayers -- send the Feds about $100 billion annually to underwrite SNAP so that poor people can choose poor food to get to poor health. We then spend a whole lot more money than that through Medicaid to pay the costs of all that disease care. Who, exactly, wins in this scenario?
Not a soul -- which may explain why SNAP evokes rather passionate opposition from some quarters.
But if SNAP as it exists is encumbered by unintended consequences, and bumping families off SNAP simply adds insult to injury while harming the economy at large and hindering human potential -- where might we go from here? How about along that neglected middle path.
First, rather than our current penny wisdom and pound foolishness, we might invoke the "in for a penny, in for a pound" adage. If it makes no sense to use public funds to help people eat the junk that propagates obesity and chronic disease and drives up costs, then it makes no sense in any context. Tax dollars underwrite public school food, too, for instance. Why should I spend money to help make more kids diabetic? It seems to me the same camp that opposes SNAP opposes the "nanny state" intrusion of such things as getting soda and cupcakes out of the schools. Let's go in for a pound, and tether public funds for sustenance to real food everywhere. Such a rising tide might help lift all boats by raising the quality of our food supply in all of its public incarnations and lifting the currently rather deplorable standard of our national health.
Second, if we are going to consider some standard of nutritional quality to guide what is permissible and what is not for SNAP at least, if not other quarters, we need an objective measure to avoid bogging down in interminable squabbling based on competing opinions and conflicted interests. Many such approaches exist, and others could be devised, but as it happens, I am the principal inventor of the only nutritional guidance system in the world (to the best of my knowledge) thus far shown to correlate directly with health outcomes, including all-cause mortality. Research just presented at the American Public Health Association meeting further suggests that the system, which uses a 1 to 100 scale, the higher the number, the more nutritious the food, facilitates choices better than all of the alternatives. And out in the real world, the system -- which has been applied to roughly 100,000 foods so far -- is associated with stunning effects -- such as the loss of more than 100 pounds just by trading up the quality of grocery choices in every aisle of the supermarket. Such a system could be applied to SNAP in a variety of ways -- including the establishment of objective thresholds of nutritional quality by category for which SNAP dollars could be used.
Third, we might consider that our problem with poor people using public assistance to buy junk food really originates with the existence in our culture of "junk" as a food group in the first place. There would be no way to use food assistance on junk food if food and junk were reliably separate things, as they should be. I've addressed the perilous foolishness of our "nudge nudge, win wink" attitude about ingestible rubbish before, and so for today's purposes will leave it at that.
Fourth, we might try spending a little to save a lot. We have all heard that an ounce of prevention is worth a pound of cure, but you have to secure that ounce before the pound becomes necessary. In other words, you have to spend to save. SNAP seems to invite its detractors to swing a big stick, but why not consider the far more appetizing carrot? We might link a comprehensive, soup-to-nuts program of financial incentives to an objective and validated measure of nutritional quality, and expand and contract the purchasing power of SNAP vouchers in accord with that metric. Buy a bread in the bottom quartile of bread scores, in other words, and your dollar is worth a dollar. Buy a bread in the top quartile, and your dollar is worth two dollars. Such thinking is already applied to produce, but there are many barriers to produce intake other than cost. Extending this approach to all foods, based on an objective measure of nutritional quality, would provide far greater leverage.
Leverage to what end? There would not need to be much shift in food purchases to the better before the chronic disease needle started to move. All available information suggests it would cost vastly less to incentivize the selection of better breads and chips and pasta sauces than to keep paying for visits to the endocrinologist, coronary bypass and bariatric surgery. We shouldn't just trust the idea -- we should pilot it and verify.
If the approach, which I have called FINGER TIPS, worked as intended -- and we should let the data decide -- then why stop with SNAP? A similar approach could readily populate private sector opportunities. Imagine, for instance, if insurance companies and self-insured employers routinely considered where their members bought food. Such companies could approach supermarkets and offer both to place a good nutrition guidance system in the store, and to provide a financial incentive system linked to it as an enhancement to the loyalty card program. The grocer would be able to promote the combination of nutrition guidance and financial rewards, and profit by growing market share. Shoppers would save money for choosing better food, which in turn could produce dramatic health benefits, and the opportunity to shift to loving foods that love us back. And the insurers, if they kept premiums fairly constant but reduced spending even slightly on chronic disease care, would increase their profit margins. Everyone, in other words, would win -- and it's an approach even ardent civil libertarians could love, because it's all carrot, no stick.
I believe food stamps could be reimagined, and the result could be a win for all concerned. I see many more challenges in the realm of health promotion with just such win-win potential.
But for now they languish, because we tend to dismiss the legitimacy of one another's arguments. They languish because ideology trumps epidemiology, instead of vice versa. They languish because of the common crackle of discord, and the pop to opposing corners. I believe if we could just get past such crackle and pop, fixing food stamps and much else that ails us -- could be a SNAP.
-fin
In his new book, DISEASE PROOF, Dr. Katz discusses such win-win ideas for putting weight loss and health on a path of lesser resistance, and lays out the skill set for getting there now, in the world as it is. DISEASE PROOF is available in bookstores nationwide and at:
Dr. David L. Katz; www.davidkatzmd.com