08/13/2013 06:34 pm ET Updated Oct 13, 2013

Finding Health, Keeping the Money: Needles in the Nation's Haystacks

I favor food assistance programming. But we do tend to spend a lot of money helping poor people get poor food on their way to poor health, and then a whole lot more money to cover the costs associated with that poor health. This involves a fair amount of losing and some weeping, and very little finding and keeping. I think we can do a whole lot better. Please hold that thought.

Collectively, we seem to have elected ourselves a Congress whose measure of productivity is filibustering attempts to pass reasonable legislation related to filibustering. I'm sure we are all very proud.

Even so, our Congress is constantly busy. In between failed attempts to undo legislation we already have and successful attempts at not generating legislation we need, Congress has also managed to direct its stultifying discord at the Farm Bill. Maybe it's particularly apt, or at least suitably bucolic, that the Farm Bill should succumb to quagmire over what amounts to little more than a tiny needle in a massive haystack. Specifically, the whole enterprise was recently siloed over the fate of 5 million of the nearly 50 million food stamp recipients.

It's hard to sort out the dollars involved, or at least I find it so. That may be intentional, creating terrific opportunities to play games with fuzzy math and call everyone else in the Capitol a liar during those rare moments when failing not to stop filibustering loses its charms. But, as best I can tell, the whole controversial thing amounts to about 1/1000 of the Farm Bill price tag. Again, we can only admire an operation that keeps its eye on so tiny a ball, even if at the expense of actually playing any innings. I sleep better at night knowing that while massive and arguably misdirected subsidies persist, at least my personal share of the rounding error is under very close scrutiny.

Supposedly, those dollars are what all the vitriol is about. Or, if this is really about ideology, the dollars provide the alibi. The argument is that the food stamp program -- now known as the Supplemental Nutrition Assistance Program, or SNAP -- is expensive, which is true. Limiting SNAP expenditures is about trimming budgets, and ostensibly, saving money.

But what if the opposite were true? What if support for SNAP reliably saved taxpayer money? If this is really an argument over ideology in disguise, I suppose the fighting might persist -- but it would at least be harder to justify. And maybe it could stop.

I am certainly not looking to pick any fights, but I doubt it will surprise anyone that as a public health type who reliably leans left of center, I support the SNAP program. I do favor the assessments that helping poor families get enough to eat is both the right thing to do, and a way to avoid the far greater expenses induced down the line by serious malnutrition. I personally know decent hardworking people who have fallen on bad times over the years. I know that there but for the grace of providence might go I, and my family. I know that even those who don't want handouts can fall, and need a hand up.

But then again, even SNAP supporters can acknowledge the liabilities involved. SNAP is intended to help those who have the most trouble affording food, and we know that in general, poor households tend to eat far less well -- with or without SNAP support -- than more affluent households. They also tend to have worse health.

So, stated bluntly, SNAP consumes something approximating $100 billion a year to help poor families get poor food, and then wind up with poor health. Admittedly, that's a bit harsh -- but it's also a pretty fair approximation of the truth. And the question is: who, exactly, wins in this scenario?


With SNAP, poor households can eat, but not necessarily well -- so the SNAP beneficiaries who wind up with resultant chronic diseases such as diabetes, lose. We taxpayers spend a lot of money now to support SNAP, only to wind up needing to spend a lot more money later to support Medicaid, which covers the costs of all that medical care, so we lose, too. And a cash-strapped government wrestling with the federal debt loses as well.

One approach to fixing this is legislating how SNAP vouchers can be spent. But only so much good can be done by telling people what they can't eat. Besides, people don't like the receiving end of a swung stick any more than horses do, whether they are SNAP beneficiaries or not.

There are some very sensible attempts to fix this using carrots, or rather -- carrot subsidies. The USDA has programming that discounts produce for SNAP beneficiaries. There is evidence that when the cost of vegetables and fruits is lowered, their consumption does go up. Such programming is a good idea, and effective so far as it goes. But it doesn't go nearly far enough, for two important reasons.

One is that, unfortunately, fresh produce makes up a fairly small part of the typical American diet, SNAP or no SNAP. That should change, but even with decades of dedicated effort in the form of such programs as "5-a-Day," it has not changed yet. I don't suggest you hold your breath.

The second problem is that cost is only one of many barriers to vegetable and fruit intake. Some people wouldn't eat Swiss chard if it were given away for free. Some people have no idea what to do with Brussels sprouts. Some people can't find the produce they enjoyed as a child. Some people spend money on a peach or tomato that tastes like plastic and are disinclined to try again. In contrast, Cheez Doodles always taste just like they should.

There are many barriers to vegetable and fruit intake. I know, because colleagues and I have studied this very issue. Such barriers can, of course, be overcome -- and we should work to do just that -- but in the interim, there is only so much leverage we can exert on the quality of a typical household's diet if the only place we plant our lever is in the produce aisle.

We could do a whole lot more to shift diet quality, and consequently health, if we had leverage in every aisle of the store. And we do, if we choose to apply it.

The reason for produce aisle incentives is that everyone agrees fresh produce is nutritious. The reason for a lack of incentives elsewhere is the trouble with getting people to agree on better nutrition for all the items in bags, boxes, bottles, jars and cans. But that is not an insurmountable problem.

Expert colleagues and I have collaborated to develop an objective scoring system that measures overall nutritional quality that can be applied to every food in every category. You won't be surprised to learn that there is more and less nutritious bread; more and less nutritious breakfast cereal; more and less nutritious pasta sauce. We know that subjectively, and there is no reason we can't know it objectively as well. We do -- in the form of this system that considers more than 30 nutrient properties and puts them all together into a single number between one and 100, the higher the number, the more nutritious the food. Scores have thus far been generated for just more than 100,000 foods. That's not everything in the U.S. food supply, but it's a big chunk.

We have evidence, in the form of a study conducted at the Harvard School of Public Health in approximately 100,000 people, that the higher the average score of foods consumed using this system, the lower the rate of chronic disease and premature death. In other words, trade up your choices in every aisle of the supermarket (or bodega), and you are less likely to develop obesity, diabetes or heart disease. There is also anecdotal evidence attached to this same system of weight loss in excess of 100 pounds, again just by trading up food choices in every aisle. One of the many virtues of "more nutritious" food is that it helps us fill up on fewer calories, which in turn allows for weight loss without constant hunger.

Which brings us to the conclusion I reach, in common with some of the world's leading health economists: subsidizing better choices in the grocery store is a lot less expensive than stays in the ICU. We don't need to prevent very many cases of diabetes, heart disease or bariatric surgeries to save back the costs of incentives for nutritious foods, 10 times over. We could help poor people choose good food to get to good health, and save a ton of money doing it. Everybody could win.

We have early evidence in support of this, courtesy of research now ongoing. It suggests that both reliable nutrition guidance and financial incentives help people trade up their choices, and in accord with intuition, they work better together than either alone. They also seem to work best for those who most need help -- such as the SNAP population.

There is a golden opportunity to test this model in a SNAP population at the level of a city, county or state. Once proven successful at saving both health and dollars, this approach should refashion our national food assistance policies. And if this works for SNAP beneficiaries, why stop there? Private insurers could underwrite incentives for objectively more nutritious foods, code them into supermarket loyalty card programs, and increase their profit margins by reducing their disease-care expenditures. Again, everybody could win.

The prevailing status quo tends to be penny wise and many pounds foolish. I believe the bright future of health promotion is redolent with win-win opportunities that allow for finding health, and keeping money as we do so. Finding such opportunities in the Farm Bill should be a whole lot easier than spotting needles in the nation's haystacks. But just in case it isn't, here's a final bit of pragmatism: you can pick up a pretty decent metal detector for less than $100.


Dr. David L. Katz;

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