By Kaylin Hewitt
Food insecurity is a “household-level economic and social condition of limited or uncertain access to adequate food,” and has been recognized as a problem in the U.S. since the 1980s (USDA 2021; Fraser et al. 2021). Among U.S. households with children, those headed by a single mother remain more likely to experience food insecurity than other familial configurations. In 2020, women-led households with children experienced food insecurity at a rate of 27.7%, significantly higher than the national average of 10.5% (USDA 2021). In contrast, married-couple families and families headed by a single father experience food insecurity at rates of 9.5% and 16.3%, respectively (USDA 2021). Food insecurity affected 6.1 million children in 2020 (USDA 2021). Household food insecurity levels reached a 20 year low in 2019, at 10.9% (Feeding America 2021). Poverty and unemployment, two major contributors to food insecurity, had also reached lows that year (Feeding America 2021). The onset of the COVID-19 pandemic significantly increased unemployment, poverty, and food insecurity, exacerbating these effects on groups including Black, Hispanic, and Native Americans as well as women and children. Feeding America projected a 3.0% increase in food insecurity among all Americans between 2019 and 2020, from 10.9% to 13.9%, predicting just a 1.0% decrease to 12.9% in 2021 (Feeding America 2021). Despite significant government funding and outreach, household food insecurity levels have not decreased below 10% in the past two decades (Miller & Thomas 2020).
Food insecurity adversely affects the health of adults, infants, and children. Childhood food insecurity is correlated with an increased risk of anemia, hypertension, and cognitive problems, as well as lower nutrient intake, depression, and poorer oral and general health (Gundersen and Ziliak 2015). In adults, food insecurity can contribute to lower nutrient intake, higher rates of mental health problems, diabetes, hypertension, poorer health, and poor sleep outcomes (Gundersen and Ziliak 2015). Food-insecure mothers are more than twice as likely to report mental health issues as those who are food-secure (Gundersen and Ziliak 2015). Mothers experiencing food insecurity also report lower rates of breastfeeding due to stress and decreased nutrient intake (Gross et al. 2019). Sensitive periods including pregnancy, infancy, and toddlerhood denote increased vulnerability for families experiencing food insecurity.
The federal government spent $96 billion in 2018 to fund its 14 USDA food and nutrition assistance programs (Miller & Thomas 2020). Spending increased to $132 billion during 2020, largely due to the Coronavirus pandemic (USDA 2021). The Supplemental Nutrition Assistance Program (SNAP) is the largest of such programs, aiding an estimated 41.5 million people with its 82% enrollment rate across the U.S. in 2021 (USDA 2021). Figure 1 depicts the distribution of SNAP participation in each state. In 2018, 47.5% of households receiving SNAP benefits were food insecure (Miller & Thomas 2020). The Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) complements SNAP and aims to reduce food insecurity among vulnerable groups; in FY2021, WIC served 6.2 million women, infants, and children under 5 nationwide (USDA 2021). However, its enrollment rate for eligible individuals remains around 57% (FRAC 2021). Figure 2 shows WIC eligibility across U.S. regions. Between February 2020 and February 2021, WIC participation among women and infants decreased by 5.5% and 5.4%, respectively, but participation among children increased by 9.3% (FRAC 2021).
The National School Lunch Program (NSLP) combats childhood food insecurity by providing free or low-cost meals to 29.6 million children in schools across the country (USDA 2021). In conjunction with the NSLP, the Community Eligibility Provision provides free breakfast and lunch for children in schools where a significant proportion of the student population meets eligibility criteria (Miller & Thomas 2020). Similarly, the Child and Adult Care Food Program (CACFP) offers reimbursement for meals and snacks to children and adults who attend eligible child and adult daycare centers. Around 4.2 million children and 138,000 adults participate in this program nationwide (USDA 2021).
The COVID-19 pandemic increased the severity and uncertainty of food insecurity for many families. To address increased food insecurity, local, state, and national governments jointly modified national food assistance programs to increase eligibility and benefit amounts (Fraser et al. 2021). In response to the pandemic, congress increased household SNAP benefits by 15%, which remained in effect until September 30, 2021 (USDA 2021). In food security crises, SNAP and child nutrition programs are the most modified assistance programs (Fraser et al. 2021). Similarly, the American Rescue Plan Act increased WIC fruit and vegetable benefits from $9-$11 to $35 per month in 2021, which has since been extended through March of 2022 (NWA 2022). The NSLP issued child nutrition waivers that allowed guardians to pick up school meals during widespread school closures in 2020 and 2021 (FRAC 2022). Women-led households with children are increasingly vulnerable to the threat of food insecurity. Leaders of food assistance programs including SNAP, WIC, NSLP, and CACFP play an integral role in providing food and nutrition access for these groups. Food-insecure women, infants, and children may benefit from a variety of policy changes; however, this brief will focus on alterations to the WIC program, as its relatively low participation rate demonstrates a greater potential for improvement.
Though research shows WIC’s effectiveness in improving health outcomes and fruit and vegetable intake for women and children, WIC benefits alone are not enough to support a family. Just 57% of WIC-eligible individuals participate in the program (FRAC 2021). Traditionally, WIC has combined elements of monetary aid with nutrition education services, with participants typically attending upwards of four 45-minute appointments per year (Neuberger 2020). The three main surveyed reasons for lack of WIC participation among eligible families include misinformation, clinic experience, and shopping experience (Neuberger 2020). By streamlining the WIC enrollment process and offering virtual services, participation rates can be increased, thus reducing food insecurity among women and children in the U.S.
The COVID-19 pandemic prompted dramatic changes in WIC operations. USDA waivers attempted to increase its accessibility and ease of use during COVID-19. The physical presence waiver shifted appointments to a virtual format. During the pandemic, 99% of local WIC agencies conducted certification appointments virtually or by phone, compared to just 12% prior (USDA 2021). One-on-one nutrition and breastfeeding appointments also largely took place over the phone. These changes demonstrate promising outcomes. In a 2019 Vermont case study on virtual WIC processes, 80% of scheduled phone appointments were kept, compared to 49% of in-person appointments (Neuberger 2020). In a 2016 California case study, 82% of WIC participants stated they would prefer video appointments to in-person (Neuberger 2020). The remote benefit issuance waiver, also issued during the pandemic, eliminated the requirement for participants to pick up electronic benefits transfer (EBT) or voucher cards in person, allowing them to instead be mailed or picked up (USDA 2021). The Vermont case study found that 40% of WIC participants saved 40 minutes or more by shifting to phone rather than in-person appointments (Neuberger 2020). Further, online services reduce the risk of exposure to COVID-19 by eliminating the need for travel and face-to-face interaction. The majority of state WIC agencies reported that shifting to remote meeting and benefit issuance formats increased WIC’s accessibility, convenience and efficiency, while improving participants’ food access during the pandemic (USDA 2021).
Despite Congress’ 2010 mandate requiring the shift from paper vouchers to EBT cards by 2020, 12 state agencies (including Delaware, Georgia, District of Columbia, Puerto Rico, and 8 Native American regions) remain in the statewide implementation process (USDA 2022). Among the 77 state agencies that have adopted EBT, 66 offer an online format, while 11 remain offline, requiring participants to reload benefit cards in person every four months (USDA 2022). Researchers found a correlation between EBT format and WIC participation rates during the pandemic. States with offline EBT saw a 4.43% decrease in participation, while online EBT states experienced an increase of 3.49% (Vasan et al. 2021). In pandemic and non-pandemic times, online EBT programs decrease barriers among participants and encourage WIC usage.
Recent research demonstrates further positive impacts of implementing virtual WIC processes, including reducing racial and gender inequities, which have worsened with the COVID-19 pandemic. Women experience an increased risk of poverty due to factors including the wage gap, societal expectations for women to provide childcare, and the effects of pregnancy on career and educational outcomes (Cawthorne 2008). In 2020, Black and Hispanic women experienced poverty at rates of 21.5% and 18.8%, respectively (Haider & Roque 2021). Similarly, Black and Hispanic households remain about twice as likely as white households to experience food insecurity—a gap that has remained persistent for 20 years (Haider & Roque 2021). Prolonged food insecurity is correlated with many negative health outcomes, including nutrient deficiencies, hypertension, and diabetes. Women and children are more susceptible to poverty and food insecurity, and thus experience a greater risk for such health impacts. Because of Black and Hispanic women’s overrepresentation in food-insecure groups, they also may experience disproportionate health outcomes. By expanding the program’s reach, both infant mortality rates and maternal health can be improved–especially by increasing the percentage of Medicaid recipients who use WIC (Vasan et al. 2021). Ultimately, participants perceived decreased compliance costs with online WIC programming, which impacted their decision to continue enrollment (Barnes & Petry 2021). By shifting to online processes, agencies can reduce the program’s administrative burden, which includes filling out forms, providing documentation, and attending in-person consultations (Barnes & Petry 2021).
If no policy change was made, we could expect participation and food security rates to follow recent trends. Between 2015 and 2019, total WIC participation declined by an average of 5.5% per year, before stagnating around 2020 (USDA 2022). Total enrollment in 2021 was 6,244,288 participants nationwide (USDA 2022). If participation declined by 5.5% for 2022, assuming a food cost of $38.91 per person per month ($466.92 per person per year, calculated using the average WIC food cost between 2018-2021), it would result in a savings of $160,356,670, or 3.27% of the annual WIC budget. This estimate does not account for administrative or additional costs. However, such a decline in participation would indicate an increase in food insecurity among the women, infants, and children who no longer participate in the program. Of 3,818 WIC participants surveyed in Iowa, 54.3% reported their level of food security as “high,” 28.9% reported it as “low,” and 16.8% reported it as “very low” (Iowa Department of Public Health 2021). National WIC data did not appear to be available for this measure. Although it is difficult to make assumptions about the national WIC population based on a single-state study such as this, these data can be helpful in roughly estimating the number of people who may experience food insecurity as a result of leaving the program. For this example, we assume that the proportions of high, low, and very low food security in Iowa reflect those of the current national WIC population. If a decline of 5.5%, or 343,435 people, occurred, we could expect to see roughly 99,252 of them experience low food security, and 57,679 of them experience very low food security after leaving the program. A 2016 study found that WIC reduced child food insecurity by 20% (Kreider, Pepper, and Roy 2016). Children leaving the program would likely see an increase in their risk of food insecurity as well. Because WIC increases equitable outcomes in food and nutrition access for low-income women, infants, and children, a decrease in participation would constrain its reach, therefore reducing equity in food security for this population. Thus, changes such as program modernization are necessary to prevent decreased participation and negative impacts on food security.
It is difficult to estimate the cost of implementing online WIC appointments and EBT. Costs for remote appointment options would largely consist of technology upgrades for local WIC departments to allow for videoconferencing. The California case study mentioned above reported a cost of $10 per web camera, as well as $6,000 per year to facilitate virtual meetings through an online platform called Healthie (Neuberger 2020). If each of the 1,900 local WIC agencies purchased three web cameras and access to the Healthie platform for one year, the total cost would equal $11,457,000. The $57,000 allocated toward web cameras is assumed to be a one-time cost, but may be lower if some local agencies already have such technology. It is unclear whether videoconferencing would result in new participation, but it is likely to aid in retention. It is difficult to estimate the cost of shifting from offline to online EBT; these costs would largely consist of technology upgrades. If current participation rates in offline states (1,219,090) increased by 3.49%, as occurred in online states during the pandemic, we could expect an additional 42,546 WIC participants following this shift (Vasan et al. 2021). If we expect food costs to increase by $466.92 per person per year for this population, the additional total cost would equal $19,865578. Again, this would not account for administrative or additional costs. Calculable food and technology cost estimates for this alternative total $31,322,578.
Based on positive WIC participation outcomes following USDA waivers during the COVID-19 pandemic, evidence suggests that shifting toward virtual and online formats for appointments, recertification, and EBT cards is in the best interest of WIC agencies and those they serve. By permanently upholding many of the changes made during the pandemic, WIC agencies can improve participant experience as well as enrollment and retention rates, thereby improving nutrition and food security for women, infants, and children across the country.
Bibliography
Barnes, Carolyn, and Sarah Petry. 2021. “‘It Was Actually Pretty Easy’: COVID‐19 Compliance Cost Reductions in the WIC Program.” Public Administration Review, September, 10.1111/puar.13423. https://doi.org/10.1111/puar.13423.
Cawthorne, Alexandra. 2008. “The Straight Facts on Women in Poverty.” Center for American Progress (blog). October 8, 2008. https://www.americanprogress.org/article/the-straight-facts-on-women-in-poverty/.
Feeding America. March 2021. “The Impact of the Coronavirus on Food Insecurity.” https://www.feedingamerica.org/sites/default/files/2021-03/National%20Projections%20Brief_3.9.2021_0.pdf
FRAC Food Action & Research Center. June 2021. “One Year of WIC During COVID-19.” https://frac.org/wp-content/uploads/One-Year-of-WIC-During-COVID-19.pdf
FRAC Food Action & Resource Center. February 2022. “School Meals Report, 2020–2021 School Year.” https://frac.org/wp-content/uploads/SchoolMealsReport2022.pdf
Fraser, Katherine Tomaino, Sarah Shapiro, Craig Willingham, Emilio Tavarez, Joel Berg, and Nicholas Freudenberg. 2021. “What We Can Learn from U.S. Food Policy Response to Crises of the Last 20 years – Lessons for the COVID-19 Era: A Scoping Review.” SSM – Population Health 17 (November): 100952. https://doi.org/10.1016/j.ssmph.2021.100952.
Gross, Rachel S., Alan L. Mendelsohn, Mayela M. Arana, and Mary Jo Messito. 2019. “Food Insecurity During Pregnancy and Breastfeeding by Low-Income Hispanic Mothers.” Pediatrics 143 (6): e20184113. https://doi.org/10.1542/peds.2018-4113.
Gundersen, Craig, and James P. Ziliak. 2015. “Food Insecurity And Health Outcomes.” Health Affairs 34 (11): 1830–39. https://doi.org/10.1377/hlthaff.2015.0645.
Haider, Areeba, and Lorena Roque. 2021. “New Poverty and Food Insecurity Data Illustrate Persistent Racial Inequities.” Center for American Progress (blog). September 29, 2021. https://www.americanprogress.org/article/new-poverty-food-insecurity-data-illustrate-persistent-racial-inequities/.
Iowa Department of Public Health. 2021. “Extent of Food Insecurity among Iowa WIC Participants in 2021.” https://idph.iowa.gov/Portals/1/userfiles/204/Food%20Security/Final%20Food%20Security%20Survey%20Report%202021.pdf.
Kreider, Brent, John V. Pepper, and Manan Roy. 2016. “Identifying the Effects of WIC on Food Insecurity Among Infants and Children.” Southern Economic Journal 82 (4): 1106–22. https://www.jstor.org/stable/26632309.
Miller, Daniel P., and Margaret M.C. Thomas. 2020. “Policies to Reduce Food Insecurity: An Ethical Imperative.” Physiology & Behavior 222 (August): 112943. https://doi.org/10.1016/j.physbeh.2020.112943.
NCES National Center for Education Statistics. 2012. “Kindergarten Entry Status: On-Time, Delayed-Entry, and Repeating Kindergartners,” 9. https://nces.ed.gov/programs/coe/pdf/coe_tea.pdf.
NWA National WIC Association. 2022. “New Report Finds WIC Benefit Bump Resulted in Increased Fruit and Vegetable Consumption among WIC-Enrolled Children.” National WIC Association. March 2022. https://www.nwica.org/press-releases/new-report-finds-wic-benefit-bump-resulted-in-increased-fruit-and-vegetable-consumption-among-wic-enrolled-children.
NWA National WIC Association. 2021. “Senate Bill Would Enhance WIC Funding Ahead of Deadline.” National WIC Association. August 5, 2021. https://www.nwica.org/press-releases/senate-bill-would-enhance-wic-funding-ahead-of-deadline.
Neuberger, Zoe. 2020. “Streamlining and Modernizing WIC Enrollment.” Center on Budget and Policy Priorities. December 17, 2020. https://www.cbpp.org/research/food-assistance/streamlining-and-modernizing-wic-enrollment.
Nutrition Policy Institute. June 2021. “Lessons Learned: Examining WIC During COVID-19 for Policy and Program Recommendations Going Forward.” https://ucanr.edu/sites/NewNutritionPolicyInstitute/files/352391.pdf.
USDA. 2021. “Changes in USDA Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Operations During the COVID-19 Pandemic: A First Look at the Impact of Federal Waivers,” December, 10. https://fns-prod.azureedge.us/sites/default/files/resource-files/FFCRA-WICWaiver-Prelim-1.pdf
USDA. 2021. “SNAP Benefits: The COVID-19 Pandemic and Beyond,” October, 3. https://www.fns.usda.gov/snap/benefit-changes-2021#:~:text=In%20response%20to%20the%20pandemic,benefit%20for%20their%20household%20size.
USDA. 2021. “Definitions of Food Security.” November 8, 2021. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/definitions-of-food-security/.
USDA. 2021. “Food Security and Nutrition Assistance.” November 8, 2021. https://www.ers.usda.gov/data-products/ag-and-food-statistics-charting-the-essentials/food-security-and-nutrition-assistance/?topicId=d7627f77-6cee-4ab9-bbb9-8c74d4778941.
USDA. 2021. “Key Statistics & Graphics.” October 8, 2021. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/key-statistics-graphics/.
USDA. 2018. “National- and State-Level Estimates of WIC Eligibility and WIC Program Reach in 2018 With Updated Estimates for 2016 and 2017 Volume I.” Final Report, 95. https://fns-prod.azureedge.net/sites/default/files/resource-files/WICEligibles2018-VolumeI.pdf
USDA. 2022. “WIC EBT Detail Status Report.” March, 2022. https://fns-prod.azureedge.us/sites/default/files/resource-files/March2022WICEBTDetailStatusReport.pdf.
Vasan, Aditi, Chén C. Kenyon, Christina A. Roberto, Alexander G. Fiks, and Atheendar S. Venkataramani. 2021. “Association of Remote vs In-Person Benefit Delivery With WIC Participation During the COVID-19 Pandemic.” JAMA 326 (15): 1531–33. https://doi.org/10.1001/jama.2021.14356.