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Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study.
PLoS Med. 2018 10; 15(10):e1002661.PM

Abstract

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) provides approximately US$70 billion annually to support food purchases by low-income households, supporting approximately 1 in 7 Americans. In the 2018 Farm Bill, potential SNAP revisions to improve diets and health could include financial incentives, disincentives, or restrictions for certain foods. However, the overall and comparative impacts on health outcomes and costs are not established. We aimed to estimate the health impact, program and healthcare costs, and cost-effectiveness of food incentives, disincentives, or restrictions in SNAP.

METHODS AND FINDINGS

We used a validated microsimulation model (CVD-PREDICT), populated with national data on adult SNAP participants from the National Health and Nutrition Examination Survey (NHANES) 2009-2014, policy effects from SNAP pilots and food pricing meta-analyses, diet-disease effects from meta-analyses, and policy, food, and healthcare costs from published literature to estimate the overall and comparative impacts of 3 dietary policy interventions: (1) a 30% incentive for fruits and vegetables (F&V), (2) a 30% F&V incentive with a restriction of sugar-sweetened beverages (SSBs), and (3) a broader incentive/disincentive program for multiple foods that also preserves choice (SNAP-plus), combining 30% incentives for F&V, nuts, whole grains, fish, and plant-based oils and 30% disincentives for SSBs, junk food, and processed meats. Among approximately 14.5 million adults on SNAP at baseline with mean age 52 years, our simulation estimates that the F&V incentive over 5 years would prevent 38,782 cardiovascular disease (CVD) events, gain 18,928 quality-adjusted life years (QALYs), and save $1.21 billion in healthcare costs. Adding SSB restriction increased gains to 93,933 CVD events prevented, 45,864 QALYs gained, and $4.33 billion saved. For SNAP-plus, corresponding gains were 116,875 CVD events prevented, 56,056 QALYs gained, and $5.28 billion saved. Over a lifetime, the F&V incentive would prevent approximately 303,900 CVD events, gain 649,000 QALYs, and save $6.77 billion in healthcare costs. Adding SSB restriction increased gains to approximately 797,900 CVD events prevented, 2.11 million QALYs gained, and $39.16 billion in healthcare costs saved. For SNAP-plus, corresponding gains were approximately 940,000 CVD events prevented, 2.47 million QALYs gained, and $41.93 billion saved. From a societal perspective (including programmatic costs but excluding food subsidy costs as an intra-societal transfer), all 3 scenarios were cost-saving. From a government affordability perspective (i.e., incorporating food subsidy costs, including for children and young adults for whom no health gains were modeled), the F&V incentive was of low cost-effectiveness at 5 years (incremental cost-effectiveness ratio: $548,053/QALY) but achieved cost-effectiveness ($66,525/QALY) over a lifetime. Adding SSB restriction, the intervention was cost-effective at 10 years ($68,857/QALY) and very cost-effective at 20 years ($26,435/QALY) and over a lifetime ($5,216/QALY). The combined incentive/disincentive program produced the largest health gains and reduced both healthcare and food costs, with net cost-savings of $10.16 billion at 5 years and $63.33 billion over a lifetime. Results were consistent in probabilistic sensitivity analyses: for example, from a societal perspective, 1,000 of 1,000 iterations (100%) were cost-saving for all 3 interventions. Due to the nature of simulation studies, the findings cannot prove the health and cost impacts of national SNAP interventions.

CONCLUSIONS

Leveraging healthier eating through SNAP could generate substantial health benefits and be cost-effective or cost-saving. A combined food incentive/disincentive program appears most effective and may be most attractive to policy-makers.

Authors+Show Affiliations

Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America.Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America.Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America.Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America.Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America.Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America.Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

30278053

Citation

Mozaffarian, Dariush, et al. "Cost-effectiveness of Financial Incentives and Disincentives for Improving Food Purchases and Health Through the US Supplemental Nutrition Assistance Program (SNAP): a Microsimulation Study." PLoS Medicine, vol. 15, no. 10, 2018, pp. e1002661.
Mozaffarian D, Liu J, Sy S, et al. Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study. PLoS Med. 2018;15(10):e1002661.
Mozaffarian, D., Liu, J., Sy, S., Huang, Y., Rehm, C., Lee, Y., Wilde, P., Abrahams-Gessel, S., de Souza Veiga Jardim, T., Gaziano, T., & Micha, R. (2018). Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study. PLoS Medicine, 15(10), e1002661. https://doi.org/10.1371/journal.pmed.1002661
Mozaffarian D, et al. Cost-effectiveness of Financial Incentives and Disincentives for Improving Food Purchases and Health Through the US Supplemental Nutrition Assistance Program (SNAP): a Microsimulation Study. PLoS Med. 2018;15(10):e1002661. PubMed PMID: 30278053.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study. AU - Mozaffarian,Dariush, AU - Liu,Junxiu, AU - Sy,Stephen, AU - Huang,Yue, AU - Rehm,Colin, AU - Lee,Yujin, AU - Wilde,Parke, AU - Abrahams-Gessel,Shafika, AU - de Souza Veiga Jardim,Thiago, AU - Gaziano,Tom, AU - Micha,Renata, Y1 - 2018/10/02/ PY - 2018/03/06/received PY - 2018/08/30/accepted PY - 2018/10/3/entrez PY - 2018/10/3/pubmed PY - 2019/4/10/medline SP - e1002661 EP - e1002661 JF - PLoS medicine JO - PLoS Med. VL - 15 IS - 10 N2 - BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) provides approximately US$70 billion annually to support food purchases by low-income households, supporting approximately 1 in 7 Americans. In the 2018 Farm Bill, potential SNAP revisions to improve diets and health could include financial incentives, disincentives, or restrictions for certain foods. However, the overall and comparative impacts on health outcomes and costs are not established. We aimed to estimate the health impact, program and healthcare costs, and cost-effectiveness of food incentives, disincentives, or restrictions in SNAP. METHODS AND FINDINGS: We used a validated microsimulation model (CVD-PREDICT), populated with national data on adult SNAP participants from the National Health and Nutrition Examination Survey (NHANES) 2009-2014, policy effects from SNAP pilots and food pricing meta-analyses, diet-disease effects from meta-analyses, and policy, food, and healthcare costs from published literature to estimate the overall and comparative impacts of 3 dietary policy interventions: (1) a 30% incentive for fruits and vegetables (F&V), (2) a 30% F&V incentive with a restriction of sugar-sweetened beverages (SSBs), and (3) a broader incentive/disincentive program for multiple foods that also preserves choice (SNAP-plus), combining 30% incentives for F&V, nuts, whole grains, fish, and plant-based oils and 30% disincentives for SSBs, junk food, and processed meats. Among approximately 14.5 million adults on SNAP at baseline with mean age 52 years, our simulation estimates that the F&V incentive over 5 years would prevent 38,782 cardiovascular disease (CVD) events, gain 18,928 quality-adjusted life years (QALYs), and save $1.21 billion in healthcare costs. Adding SSB restriction increased gains to 93,933 CVD events prevented, 45,864 QALYs gained, and $4.33 billion saved. For SNAP-plus, corresponding gains were 116,875 CVD events prevented, 56,056 QALYs gained, and $5.28 billion saved. Over a lifetime, the F&V incentive would prevent approximately 303,900 CVD events, gain 649,000 QALYs, and save $6.77 billion in healthcare costs. Adding SSB restriction increased gains to approximately 797,900 CVD events prevented, 2.11 million QALYs gained, and $39.16 billion in healthcare costs saved. For SNAP-plus, corresponding gains were approximately 940,000 CVD events prevented, 2.47 million QALYs gained, and $41.93 billion saved. From a societal perspective (including programmatic costs but excluding food subsidy costs as an intra-societal transfer), all 3 scenarios were cost-saving. From a government affordability perspective (i.e., incorporating food subsidy costs, including for children and young adults for whom no health gains were modeled), the F&V incentive was of low cost-effectiveness at 5 years (incremental cost-effectiveness ratio: $548,053/QALY) but achieved cost-effectiveness ($66,525/QALY) over a lifetime. Adding SSB restriction, the intervention was cost-effective at 10 years ($68,857/QALY) and very cost-effective at 20 years ($26,435/QALY) and over a lifetime ($5,216/QALY). The combined incentive/disincentive program produced the largest health gains and reduced both healthcare and food costs, with net cost-savings of $10.16 billion at 5 years and $63.33 billion over a lifetime. Results were consistent in probabilistic sensitivity analyses: for example, from a societal perspective, 1,000 of 1,000 iterations (100%) were cost-saving for all 3 interventions. Due to the nature of simulation studies, the findings cannot prove the health and cost impacts of national SNAP interventions. CONCLUSIONS: Leveraging healthier eating through SNAP could generate substantial health benefits and be cost-effective or cost-saving. A combined food incentive/disincentive program appears most effective and may be most attractive to policy-makers. SN - 1549-1676 UR - https://www.unboundmedicine.com/medline/citation/30278053/Cost_effectiveness_of_financial_incentives_and_disincentives_for_improving_food_purchases_and_health_through_the_US_Supplemental_Nutrition_Assistance_Program__SNAP_:_A_microsimulation_study_ L2 - http://dx.plos.org/10.1371/journal.pmed.1002661 DB - PRIME DP - Unbound Medicine ER -