09.08.16

Exclude sugary drinks from nutrition program, but exclude stigma too

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Supplemental Nutrition Assistance Program logo

Recent years have seen periodic calls for unhealthy foods, most prominently sugary drinks, to be excluded from items that can be purchased through the Supplemental Nutritional Assistance Program (SNAP). SNAP is the federally-funded program that helps low-income people in the United States, presently about 45 million, pay for food. Several states and locales have sought waivers to permit these exclusions, including New York City’s 2010 proposal to ban sugary beverages, and Maine’s continued effort to ban use of SNAP to purchase sugary beverages or candy. This past January, the National Commission on Hunger, appointed by Democratic and Republican Members of Congress, recommended excluding sugary-sweetened beverages from SNAP eligibility. Public health experts widely support such changes to SNAP.

The public health rationale for banning sugary drinks and possibly other unhealthy foods from SNAP eligibility is straightforward. These foods contribute to high levels of obesity in the United States (and globally), which is a major risk factor for diabetes, heart disease, and other illnesses. Sugary drinks have been recognized as a particular culprit. Why should funding for a nutrition program be used in ways that contribute to malnutrition rather than better nutrition, that harm health rather than protecting it?

Yet to date, the U.S. Department of Agricultural (USDA), responsible for SNAP, has denied all waivers. There are a mix of reasons for USDA’s denials, including questions about how to define unhealthy foods that would be excluded, practical technological questions about implementing exclusions, and in the case of Maine, concerns about an inadequate evaluation plan.

USDA’s most significant concerns, particularly if we consider a narrowly tailored ban, such as only for sugary beverages, are concentrated in two areas. One is a question of effectiveness. Most SNAP participants pay for some of their food with their own money, so might simply pay for any banned food with cash, and purchase some of the food they would have paid for with cash through SNAP instead. A second is a set of concerns involving singling out the poor. If SNAP participants are unaware of exclusions, they may find items rejected at the checkout counter, which could be stigmatizing, and even deter some people who are eligible for SNAP from participating in the program. An exclusion might be seen to “‘perpetuate the myth’ that food-stamp users made poor shopping decisions.” And it would restrict the choices of SNAP participants (or at least for those for whom SNAP funding comprises most or all of their food purchases) in a way that most of us are not so confined.

Many anti-hunger groups oppose any restrictions on foods and beverages available through SNAP primarily for this second set of reasons. Meanwhile, USDA recommends a focus on incentives to encourage healthy food purchase rather than restrictions on unhealthy foods.

These are powerful reasons, particularly the risk of stigma, something that we need to eliminate, not risk exacerbating. Yet I also agree with Kelly Brownell, dean of Duke University’s Sanford School of Public Policy: “The government should not be in the business of making people sick.”

The solution, I would suggest, comes in a comprehensive sweep of policies, of which a targeted ban on unhealthy foods – perhaps starting where there is the most support, sugary drinks – would be one prong. Such an approach, outlined below, would have several aims. First, echoing Dean Brownell and other supporters of a ban, it would begin to move the government out of the role of supporting health-degrading behaviors, at least in the realm of government nutrition programs, and use government’s regulatory authorities to extend this discouragement of unhealthy eating beyond SNAP. Second, it would include actions to incentivize healthy eating. And third, it would protect against stigma.

More particularly, these policies could include:

1. Soda and other sugary drinks would no longer be eligible for purchase through SNAP. However, we should not impose on the poor a burden that we would not accept for ourselves (for those of us not on SNAP). Yes, there is a difference insofar as SNAP is a government benefit, as distinct from how we choose to spend our own dollars. Yet the point of the SNAP exclusion is to use government policy to deter people from purchasing sugary drinks by adding an extra burden. If we impose that burden on low-income people, we should be willing to impose that burden on ourselves, as well, on all of us.

Therefore, a tax on sugary drinks should complement the SNAP exclusion. And besides, if we are serious about improving nutrition, it would seem silly to restrict soda from SNAP purchases, an approach that thus far (not having been tried) lacks evidence on its effectiveness, when there is a growing body of evidence that taxes on unhealthy beverages do lead to reduced consumption, as in Mexico and Berkeley, California. Other broadly applicable policies on limiting sugary drink consumption for the population at large (such as New York City’s attempt to restrict soda portion size, ultimately struck down by a court, which found that the city’s Board of Health had exceeded its authority), would be appropriate as well.

2. Discouraging sugary drinks purchases through a SNAP exclusion may lead to reduced consumption. Encouraging vegetable and fruit purchases through a SNAP incentive program would almost surely increase consumption of these very healthy foods. A pilot program that provided SNAP households an extra 30 cents for every dollar spent on vegetables and fruits found that these households increased vegetable and fruit purchases by 26% compared to SNAP households in the same Massachusetts county that did not receive this incentive.

A sugary drink exclusion should be paired with an incentive program for purchasing vegetables and fruits, such as by taking that pilot program national. Importantly, this would also greatly increase support for a sugary drink exclusion among SNAP participants themselves. A 2012 poll found that 54% of SNAP participants favored excluding sugary drinks from SNAP eligibility; support grew to about 75% if the exclusion were linked to additional benefits to purchase healthy food. Other measures to encourage health eating could come from expanded nutrition education, such as through the SNAP-Ed program,which provides nutrition education and obesity prevention services, targeted to low-income individuals.

3. The risk of stigma must be treated with the utmost seriousness. Part of this entails measures to reduce the risk of SNAP participants from attempting to purchase the excluded items, namely sugary drinks. Education on the exclusion (which might include mailings and phone calls) – as well as the reasoning behind it – would be critical. Stores could be encouraged or required to identify (perhaps alongside the price label on shelves) the items that are excluded from SNAP, the converse of some stores labeling items eligible for the Supplemental Nutrition Program for Women, Infants, and Children (WIC). Perhaps non-SNAP participants could volunteer to enter a program where any of their purchases of sugary drinks are denied (not incidentally benefitting their own health), so that it would be unclear to other customers in line whether someone whose sugary drink purchase was rejected was a SNAP participant or not. Might this help avoid stigma?

It is sad – tragic, wrong – that we live in a society where people exercising their right to food by taking part in a program that comports with a government obligation to fulfill this right should feel stigmatized for doing so. We all need a helping hand sometimes. There ought to be no sense of shame when it happens to be the government, embodying our collective responsibilities, that offers this hand.

Still, in a country where the risk of such stigma cannot be taken lightly, these efforts to protect against stigma caused by the sugary drink SNAP would ideally be part of a larger sweep of measures to reduce stigma and discrimination against low-income individuals. One could start would be standardizing education in school curriculums on the full set of human rights, so that in coming generations, people who receive means-tested public benefits view this support as part of exercising their human rights, and that the broader society recognizes the same.

We need a holistic picture of health, and what health means from the most important perspective – the people whose health is at issue, in this case SNAP participants and other eligible low-income individuals. Health is physical and mental. People in awful physical health – what SNAP exclusions we hope would help protect against – may still experience lives with a sense of great dignity and meaning. But if we degrade people’s mental health, such as through discriminatory and stigmatizing behavior, downgrade sense of personhood, self-respect, then the most perfect physical health means little.

Concern about physical health ought to be matched by concern for mental health. I agree that government programs should not subsidize or inadvertently promote ill health. But program designs that stigmatize, that threaten mental well-being and dignity, is every bit (or indeed, more) harmful to health. To take one example, as sugary drinks purchased with SNAP should be relegated to the past, so too should drug testing requirements for government benefits (which do not directly apply to SNAP, though may affect SNAP recipients) and any limitations on people convicted of drug felonies from participating in SNAP (a ban is written into federal legislation but with the option for states to waive this disqualification; many states have eliminated or modified the ban, but some continue with a lifelong ban).

SNAP participants and other low-income individuals eligible for SNAP should be central to designing these policies — maximizing the potential that these policies would lead to better health, that would avoid any stigmatizing effects, and would be ones that low-income individuals themselves, along with public health experts, widely view as desirable. Imagine what a model it would be if this traditionally disempowered segment of our population began to experience public assistance programs not as a matter of rules and restrictions, hoops and hurdles, but instead as initiatives that they own, that respect them as people, that they experience as empowering and enabling them. That would be a recipe not only for healthier eating, but also for a healthier society.

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