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BACKGROUND AND OBJECTIVES:

Fifteen percent of US children live in households with inadequate food. Children who are food insecure often experience worse physical, emotional, and developmental health outcomes. Authors of previous studies have not examined the quality and cost implications of food insecurity in children.

METHODS:

This is a retrospective study of 7959 nationally representative US children (aged 1–17 years) in the 2016 Medical Expenditure Panel Survey. Households with food insecurity were identified by ≥3 positive responses to the 30-day, 10-item US Food Security Survey. Main outcomes were annual health expenditures and quality of care indicators: emergency department (ED) and inpatient use, primary care and specialist visits, routine medical and dental care, patient experience measures, and school absenteeism. Logistic and 2-part regression models were constructed to estimate outcomes conditional on sociodemographic and medical covariates.

RESULTS:

Children in households with food insecurity were more often publicly insured and had special needs compared with all other children. In multivariable logistic regression, household food insecurity was associated with significantly higher adjusted odds of an ED (adjusted odds ratio [aOR] = 1.37) or primary care treatment visit (aOR = 1.24) during the year. Household food insecurity was associated with significantly higher school absenteeism (aOR = 1.74) and lower access to care for routine (aOR = 0.55) or illness (aOR = 0.57) care. There were no differences in annual health expenditures, hospitalizations, or receipt of routine medical or dental care.

CONCLUSIONS:

Household food insecurity is associated with higher ED use and school absenteeism and lower access to care; however, it was not associated with higher annual health expenditures in children.

What’s Known on This Subject:

Fifteen percent of US children experience food insecurity. Children who are food insecure are less likely to attain healthy growth and development. The relationship between food insecurity, health care service use, quality of care, and expenditures is not well established in children.

What This Study Adds:

Using national US survey data, we found that household food insecurity was associated with higher emergency department use and school absenteeism and lower access to care quality among children; however, there were no differences in annual health expenditures.

Food insecurity is characterized by the lack of reliable access to sufficient food to support an active and healthy life.1  Authors of previous research demonstrate that children living in households with food insecurity are at risk for worse physical, emotional, and developmental outcomes.25  Public assistance programs such as the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children have helped mitigate the potentially harmful impacts of food insecurity for millions of children.68  Yet, despite these and other important investments, the rates of food insecurity among US children remain high. At present, it is estimated that ∼15% of US children live in households with inadequate access to food.1 

In recent years, a growing number of clinical organizations as well as health insurers have prioritized addressing social determinants of health including food insecurity.912  This has involved initiatives aimed at reducing food insecurity through enhanced screenings, more robust referral to community-based organizations, or in some cases, directly providing food support in the clinical setting.1315  These programs often take place within value-based payment arrangements whereby clinical organizations have financial incentives for improving quality of care and reducing health expenditures.12,16  Such investments are often predicated on beliefs that improvements in unmet social needs will lead to improvements in quality of care and reductions in health expenditures.12  Higher health expenditures have been observed among adults with food insecurity1720 ; however this relationship has not been well established in children. Authors of previous studies examining the association between food insecurity and health care use have generated conflicting results, and none have examined differences in clinical quality.2123  Better understanding the differences in pediatric health expenditures and quality of care on the basis of food security will allow for more informed evaluation of interventions to help moderate food insecurity.

Accordingly, our objective was to examine associations between household food insecurity, health expenditures, and quality of care received by US children. Specifically, we used a nationally representative survey to examine the associations between household-level food insecurity; pediatric health expenditures; and quality of care indicators, including acute care (eg, emergency department [ED] and inpatient) use, attainment of recommended routine care, patient experience of care quality measures, and school absenteeism.

We conducted an observational study using a nationally representative sample of insured noninstitutionalized US children (ages 1–17 years) appearing in the 2016 Medical Expenditure Panel Survey (MEPS).

MEPS is a longitudinal survey of US households conducted annually by the Agency for Healthcare Research and Quality.24  MEPS uses complex survey design to allow nationally representative comparisons when applying survey weights. Households were surveyed multiple times during the study period, and for each household and/or sample, there was a designated primary survey respondent. In our sample, the primary survey respondent was almost exclusively (>97%) the parent or grandparent of the index child. MEPS contains information about sociodemographics, health needs, income, insurance enrollment, and health care service use and expenditures. Health care use data are self-reported and supplemented with information collected from a sample of health care providers. When expenditure data are missing, the MEPS uses weighted hot deck statistical imputation methods, incorporating sampling weights and sociodemographic predictors, to impute missing or unavailable expenditure data.25  It has been previously estimated that among all health care events, approximately one-third of expenditures (ranging from 30% for inpatient to 38.9% for outpatient) require full imputation.25  Imputed values for race, ethnicity, and income were also used in this analysis. All imputations were obtained from the MEPS database and we did not conduct any additional imputations for missing or unavailable data.

We measured household-level estimates of food security using the 30-day, 10-item US Adult Food Security Survey used by the US Department of Agriculture.2628  The survey is used to assess the general food needs of the household as a group over the preceding 30 days by the primary survey respondent using adult-oriented questions. The survey is not intended to describe the needs of individual household members or distinguish between child-specific food needs. Authors of validation studies suggest acceptable statistical reliability when it is tested in households with children (Cronbach’s α = 0.79) and comparability with longer versions of the survey.29  However, lower reliability in distinguishing between less severe forms of food insecurity has been noted with this instrument.29  To mitigate this limitation, and to be consistent with previous use of the data set,17  we selected a conservative definition of ≥3 positive responses corresponding to low or very low household food security and classified all other children as those living in households with <3 positive responses.26,27  Sensitivity analysis was conducted, including households with marginal food security (1 or 2 positive responses).2 

Primary outcomes were the presence of any clinical service use (inpatient, ED, specialist, and primary care visits) and total health expenditures during the calendar year. We distinguished between primary care preventive and treatment visits on the basis of the recorded type of visit and diagnosis code for the visit. Annual health expenditures were defined as the sum of all insurance-paid and household out-of-pocket expenditures in 2016 US dollars. Expenditures did not include government agency services or social services unless these were billed to the insurer and/or household. We excluded expenditures related to preventive services (eg, immunizations and primary care prevention visits) because the objective was to focus on expenses for which reductions would be unlikely to compromise quality of care. Sensitivity analysis was conducted by using all annual expenditures.

We measured receipt of routine primary care medical (annual) and dental (semiannual) visits, patient experience of care quality measures, and school absenteeism due to illness. We used patient experience of care quality measures from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems Survey adapted for MEPS to measure satisfaction with health care services.30  The Clinician and Group Consumer Assessment of Healthcare Providers and Systems Survey is a validated and widely used survey instrument in which parents rate their experience with their child’s health care. This instrument has statistical reliability (>0.70) for profiling quality of care at the physician practice level.31  We measured the overall ratings of health care services and 4 questions within the domain of access and availability of care: routine care, specialty care, necessary care, and illness care dichotomized by using the top score for each question. For analyzing school absenteeism, we limited the cohort to school-aged children (≥5 years).

Sociodemographic characteristics included the child’s age, sex, household size, geographic region, and insurance status (private versus public). Government-sponsored health insurance programs such as Medicaid and the Children’s Health Insurance Program are denoted as public. Children <1 year of age were excluded because the main and secondary outcomes were annualized measures of service use and quality. For quantifying patient-level clinical risk, we identified children with special health care needs (CSHCNs), defined as children having or being at increased risk for chronic health conditions and requiring greater than usual use of health care services, using the validated CSHCN screening instrument adapted for MEPS.32 

We conceptually mapped domains of sociodemographic risk33  to available data variables, including: (1) race and/or ethnicity, (2) public insurance, (3) non-English language, (4) household income, (5) single-parent households, (6) parental education levels, (7) poor or fair mental health in ≥1 parent, (8) parental unemployment, and (9) transportation barriers. We estimated non-English primary language households using the language used to administer the MEPS to the primary survey respondent. We calculated household income as percentage of the federal poverty level. To measure medically-related transportation barriers, we constructed an index combining 2 variables: travel ≥31 minutes to usual source of care and absence of usual source of care due to transportation problems. For modeling dental service use, we included presence of dental insurance as a covariate.

We used descriptive statistics to summarize differences in covariates and outcomes between children who are food insecure versus all other children. We conducted bivariable tests of statistical significance using the Pearson χ2 test for nonparametric survey estimates and the adjusted Wald test for parametric survey estimates. Expenditure data were highly skewed. As such, we modeled expenditures using a 2-part γ regression with log link, conditional on food security and other covariates.34  To model all other outcome variables, we used logistic regression to generate adjusted odds ratios (aORs). Stata version 14.1 (Stata Corp, College Station, TX) was used in all analyses. Specifically, we used the Stata svy command with robust variance estimators to account for clustering and applied survey weights to all analyses to allow for nationally representative comparisons. We used P < .05 as the threshold for statistical significance. The Institutional Review Board at Boston Medical Center approved this study by exemption.

The study cohort included 7959 nationally representative noninstitutionalized US children. Thirteen percent resided in households with food insecurity (representative of 8.6 million US children) (Table 1).

TABLE 1

Positive Household-Level Responses to 30-Day, 10-Item US Adult Food Security Survey

Positive Responses% of Total
78.5 
5.1 
3.5 
3 or morea 12.9a 
Positive Responses% of Total
78.5 
5.1 
3.5 
3 or morea 12.9a 

Adapted from Machlin SR, Agency for Healthcare Research and Quality, Dougherty, DD. Overview of Methodology for Imputing Missing Expenditure Data in the Medical Expenditure Panel Survey. Rockville, MD: Agency for Healthcare Research and Quality; 2017; and Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security (Revised 2000). Alexandria, VA: US Department of Agriculture; 2013.

a

Denotes food insecurity.

Children in households with food insecurity were more often African American (18.2% vs 13.6%) and Hispanic (34.1% vs 23.0%) and less often white (37.4% vs 51.5%) when compared with all other children. Higher rates of public insurance (71.3% vs 34.6%) and special health care needs (29.0% vs 20.0%) were noted among children in food-insecure households when compared with all other children (P < .001 for both; Table 2). Overall, 23% of publicly insured children lived in a household with food insecurity as compared with 7% of privately insured children. Children in households with food insecurity were more likely to be poor, and their parents were more likely to be non-English speaking, single, have fair or poor mental health, be unemployed, and lack a high school degree.

TABLE 2

Demographics and Health Care Use and Quality

Sociodemographic and Medical CovariatesFood InsecureAll OtherP
Age, mean 9.5 9.0 .03 
Male sex, % 51.1 51.1 .98 
Race and/or ethnicity, %    
 White 37.4 51.5 <.001 
 African American 18.2 13.6 — 
 Hispanic 34.1 23.0 — 
 Asian American 1.1 5.5 — 
 Other or multiple 9.3 6.3 — 
English not primary language, % 19.0 10.4 <.001 
Census region   .16 
 Northeast 11.5 17.0 — 
 South 21.6 21.3 — 
 Midwest 41.2 37.9 — 
 West 25.7 23.8 — 
Public insurance, % 71.3 34.6 <.001 
CSHCN, % 29.0 20.0 <.001 
Household size, average 4.4 4.3 .15 
Household income ≤100% of FPL 36.1 14.9 <.001 
Transportation barrier,a7.8 6.2 .21 
Single parent in household, % 47.5 24.8 <.001 
Parent without high school degree,b30.1 14.3 <.001 
Parent unemployed,b8.2 3.8 <.001 
Parent with fair or poor mental health,b31.1 11.0 <.001 
Health care use    
 Annual health expenditure, $ 1368 1360 .97 
 Any ED visit, % 16.0 11.3 .01 
 Any hospitalization, % 2.1 1.5 .24 
 Any primary care treatment visit, % 33.0 35.0 .36 
 Any specialist visit, % 20.0 20.0 .98 
Quality of care indicators    
 Any school absence for illness, % 70.2 61.5 .002 
 Annual primary care preventive visit, % 42.7 50.0 .003 
 Biannual dental visit, % 16.1 21.3 .002 
 Experience of care ratings, % top score    
  Overall 53.9 48.6 .10 
  Ease of specialist referral 55.3 68.2 .005 
  Routine appointment when wanted 72.9 84.1 <.001 
  Illness care when wanted 84.2 90.5 .04 
  Ease of getting necessary care 74.2 85.7 <.001 
Sociodemographic and Medical CovariatesFood InsecureAll OtherP
Age, mean 9.5 9.0 .03 
Male sex, % 51.1 51.1 .98 
Race and/or ethnicity, %    
 White 37.4 51.5 <.001 
 African American 18.2 13.6 — 
 Hispanic 34.1 23.0 — 
 Asian American 1.1 5.5 — 
 Other or multiple 9.3 6.3 — 
English not primary language, % 19.0 10.4 <.001 
Census region   .16 
 Northeast 11.5 17.0 — 
 South 21.6 21.3 — 
 Midwest 41.2 37.9 — 
 West 25.7 23.8 — 
Public insurance, % 71.3 34.6 <.001 
CSHCN, % 29.0 20.0 <.001 
Household size, average 4.4 4.3 .15 
Household income ≤100% of FPL 36.1 14.9 <.001 
Transportation barrier,a7.8 6.2 .21 
Single parent in household, % 47.5 24.8 <.001 
Parent without high school degree,b30.1 14.3 <.001 
Parent unemployed,b8.2 3.8 <.001 
Parent with fair or poor mental health,b31.1 11.0 <.001 
Health care use    
 Annual health expenditure, $ 1368 1360 .97 
 Any ED visit, % 16.0 11.3 .01 
 Any hospitalization, % 2.1 1.5 .24 
 Any primary care treatment visit, % 33.0 35.0 .36 
 Any specialist visit, % 20.0 20.0 .98 
Quality of care indicators    
 Any school absence for illness, % 70.2 61.5 .002 
 Annual primary care preventive visit, % 42.7 50.0 .003 
 Biannual dental visit, % 16.1 21.3 .002 
 Experience of care ratings, % top score    
  Overall 53.9 48.6 .10 
  Ease of specialist referral 55.3 68.2 .005 
  Routine appointment when wanted 72.9 84.1 <.001 
  Illness care when wanted 84.2 90.5 .04 
  Ease of getting necessary care 74.2 85.7 <.001 

Bivariable tests of statistical significance were conducted by using the Pearson χ2 test for nonparametric survey estimates and the adjusted Wald test for parametric survey estimates. FPL, federal poverty level; —, not applicable.

a

To measure medically related transportation barriers, we constructed an index combining 2 variables: (1) travel ≥31 min to usual source of care and (2) absence of usual source of care due to transportation problems.

b

Denotes ≥1 parent with the indicated risk factor.

In multivariable analysis, when adjusting for differences in medical and sociodemographic factors, children in households with food insecurity experienced modestly higher odds of experiencing an ED (aOR = 1.37; 95% confidence interval [CI]: 1.03–1.82; P = .03) or primary care treatment visit (aOR = 1.24; 95% CI: 1.00–1.54; P = .04) during the year (Table 3). There was no significant difference on the basis of household food security for inpatient hospitalizations or specialist visits. Children in households with food insecurity more often missed school because of illness (aOR = 1.74; 95% CI: 1.32–2.29; P < .001) and reported lower ease when accessing routine (aOR = 0.55; 95% CI: 0.38–0.82; P = .003) or illness (aOR = 0.57; 95% CI: 0.34–0.97; P = .04) care. We found no statistically significant difference (P = .62) in regression-adjusted annual health expenditures between children in food-insecure households ($1419; 95% CI: $1091–$1749) and all other children ($1316; 95% CI: $1172–$1461). No statistically meaningful differences in overall rating of health care services or attainment of recommend routine primary medical or dental care were observed.

TABLE 3

Adjusted Odds of Health Care Use and Quality Among Children in Food-Insecure Households

aOR (95% CI)P
Health care use   
 Hospitalization, % 1.44 (0.86–2.41) .16 
 ED visit, % 1.37 (1.03–1.82)a .03 
 Primary care treatment visit, % 1.24 (1.00–1.54)a .04 
 Specialist visit, % 1.26 (0.95–1.66) .11 
Quality of care indicators   
 Any missed school due to illness, % 1.74 (1.32–2.29)a <.001 
 Annual primary care preventive visit, % 1.03 (0.81–1.32) .79 
 Biannual dental visit, % 0.90 (0.71–1.14) .36 
 Experience of care ratings, % top score   
  Overall care 0.84 (0.62–1.13) .24 
  Ease of specialist referral 0.72 (0.48–1.09) .12 
  Routine appointment when wanted 0.55 (0.38–0.82)a .003 
  Ill care when wanted 0.57 (0.34–0.97)a .04 
  Ease of getting necessary care 0.68 (0.44–1.06) .09 
aOR (95% CI)P
Health care use   
 Hospitalization, % 1.44 (0.86–2.41) .16 
 ED visit, % 1.37 (1.03–1.82)a .03 
 Primary care treatment visit, % 1.24 (1.00–1.54)a .04 
 Specialist visit, % 1.26 (0.95–1.66) .11 
Quality of care indicators   
 Any missed school due to illness, % 1.74 (1.32–2.29)a <.001 
 Annual primary care preventive visit, % 1.03 (0.81–1.32) .79 
 Biannual dental visit, % 0.90 (0.71–1.14) .36 
 Experience of care ratings, % top score   
  Overall care 0.84 (0.62–1.13) .24 
  Ease of specialist referral 0.72 (0.48–1.09) .12 
  Routine appointment when wanted 0.55 (0.38–0.82)a .003 
  Ill care when wanted 0.57 (0.34–0.97)a .04 
  Ease of getting necessary care 0.68 (0.44–1.06) .09 

All models included MEPS survey weights to allow for nationally representative comparisons. Odds ratios were modeled by using logistic regression with use and/or outcome as the dependent variable and food insecurity as the main independent variable. All models include sociodemographic and medical covariates as listed in Table 2. Comparison group for all analyses are children in households without food insecurity.

a

Denotes statistical significance at P < .05.

We first examined the effect of stratifying the sample into 3 groups: food insecurity (≥3 positive responses) versus marginal food security (1 or 2 positive responses) versus all other children (0 positive responses). The full results are presented in Supplemental Table 4. Removing children with marginal food security from the comparator modestly impacted the results. Ease of necessary care (aOR = 0.50) was significantly lower for children who are food insecure (versus all other children); however, the previously observed increase in primary care treatment visits was no longer significant (P = .06). Children in marginally food-secure households experienced statistically higher odds of ED use and school absenteeism and lower access to care for routine, illness, and necessary care when compared with all other children. There were no statistically meaningful differences when comparing children in marginal food-secure households versus children in food-insecure households across all study outcomes. Annual health expenditures were statistically similar across all 3 groups of children.

We found in this nationally representative sample of US children that household food insecurity is concentrated among low-income household, publicly insured, and racial and/or ethnic minority children. Children living in households with food insecurity had modestly higher use of ED care and higher school absenteeism rates, and their parents experienced more frequent difficulty when trying to access care. However, despite these differences, household food security does not appear to have large impacts on hospitalization rates or annual health expenditures in children.

Our results add to the existing literature in which the complex relationship between food security and health care use in children is examined in several ways.2,3,23,35  First, we described higher use of ED services among children in food-insecure households. Previous examinations of acute care use in children who are food insecure have generated conflicting results.2123  Authors of a similar study using national survey data (2002 National Survey of America's Families) also described higher odds of ED use among children in low-income food-insecure households.21  We add to these results by presenting updated data (including middle-income children), accounting for additional sociodemographic factors, and revealing modestly higher use of primary care treatment visits among children in food-insecure households. Collectively, our 2 studies suggest that disparities in ED use on the basis of food security appear persistent over the past decade despite sustained investments in nutritional supports. Because children in food-insecure households may use the ED more frequently, this clinical setting may present opportunities for identifying needs and making connections to community-based services.36 

Second, we uniquely examined differences in patient experience of care quality on the basis of food insecurity. Authors of previous studies have suggested that lacking a usual source of care and foregoing medical care is more common among children who are food insecure.21  We add to these results by showing that parents in food-insecure households report more difficulties accessing care when needed for routine and urgent issues. Our finding, consistent with increased use of ED services, reveals the hardship that some parents with food insecurity and other social stressors may experience when attempting to access the health care system. Innovations such as open access scheduling, colocation, telehealth, or combining clinical care with food resources11,37  may help improve access to health care for these families.

Finally, we found no difference in adjusted annual health expenditures based on food insecurity in children. These findings are different from what has been previously described in adults.1720  There are several potential explanations for why food insecurity manifests as higher health expenditure use in adults but not children. First, children on average use fewer health care services, and important drivers of health expenditures (inpatient, specialist, and pharmacy) (data not shown) do not appear to be impacted as much by food insecurity in children as they are in adults.1720  Second, the adverse impacts of social stressors such as food insecurity on the well-being of developing children may not become apparent for many years (or decades), whereas in adults, who experience much higher rates of chronic illness, the consequences may be more rapid. Third, socially disadvantaged children are often reliant on social services such as school-based, government agency, and community-based care, whose costs were not included in the study. Therefore, payment policies established on the basis of adult evidence may overestimate expectations for financial savings associated with interventions aimed at ameliorating food insecurity in children. Instead, when measuring the efficacy of food security–based interventions within the context of health care delivery, we suggest that improvement targets be set toward observed disparities, including improving access and/or availability of care, reducing ED use, and enabling school attendance.38  Still, additional research is needed to determine if these disparities are amenable to delivery system intervention or are caused by more systemic effects of poverty and social disadvantage. Inclusion of nonmedical expenditures such as governmental agency and community-based supports or using longer time horizons for assessing efficacy may be more revealing in children.

The mechanism for how food insecurity impacts health care use is unclear and likely extends beyond the adverse physiologic effects of nutritional deficiency. Psychological stress associated with food insecurity negatively impacts the social, emotional, physical, and developmental health of children and young adults.2,4,35,39  Moreover, research from psychology suggests that severe scarcity causes people to experience limited “bandwidth” when processing complex decisions. As such, we hypothesize that parents in food-insecure households may find themselves experiencing more difficulties navigating the complex health care system during times of childhood illness, contributing to more reliance on acute care services.5  Future studies are encouraged to examine the intersection between food insecurity and overall economic scarcity in households as it relates to use of health care services in children.

There are several methodologic limitations to consider when interpreting these results. First, we used survey data to construct the analysis. National survey data can provide robust insights; however, they are prone to missing data and reporting bias. To mitigate this limitation when appropriate, we used MEPS-derived imputed values. However, imputation is also subject to statistical error, particularly in modeling health expenditures which have particularly high degrees of missing data. Second, we used a conservative definition for food insecurity (≥3 positive responses).40  In recent years, special attention has been called to children who are living in households with marginal food insecurity.2  Our sensitivity results suggest (noting the limitation of this survey instrument in discriminating between milder forms of food insecurity) broadly that children with marginal food security may experience similar challenges with health care access. We believe authors of studies using more robust instruments for food insecurity would be better positioned to address differences in health care use between marginally-secure and food-insecure households.27  Finally, we assessed food security of the household as a group and did not use child-specific questions. Previous research has revealed more adverse outcomes when both adult and child food insecurity are present,41  and we address this limitation through selection of a more restrictive definition of food insecurity.

Acknowledging these limitations, our results reveal disparities in quality among children in food-insecure households and inform potential financial implications of interventions.

We found that household food insecurity is associated with higher rates of ED use and school absenteeism and lower access to care quality in children. However, the impacts of food insecurity on hospitalization rates and overall health expenditures may be minimal. Clinical organizations, insurers, and policymakers may take note of these findings as they partner to implement delivery system interventions to address food security in socially disadvantaged children.

We thank Ryan Walsh, BS, for assisting with article preparation.

Drs Peltz and Garg conceptualized and designed the study, developed the analysis plan, and drafted the initial manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • aOR

    adjusted odds ratio

  •  
  • CI

    confidence interval

  •  
  • CSHCN

    child with special health care needs

  •  
  • ED

    emergency department

  •  
  • MEPS

    Medical Expenditure Panel Survey

1
Coleman-Jensen
A
,
Rabbitt
MP
,
Gregory
CA
,
Singh
A
.
Household Food Security in the United States in 2017. ERR-256
.
Washington, DC
:
US Department of Agriculture, Economic Research Service
;
2017
2
Cook
JT
,
Black
M
,
Chilton
M
, et al
.
Are food insecurity’s health impacts underestimated in the U.S. population? Marginal food security also predicts adverse health outcomes in young U.S. children and mothers
.
Adv Nutr
.
2013
;
4
(
1
):
51
61
3
Shankar
P
,
Chung
R
,
Frank
DA
.
Association of food insecurity with children’s behavioral, emotional, and academic outcomes: a systematic review
.
J Dev Behav Pediatr
.
2017
;
38
(
2
):
135
150
4
Rose-Jacobs
R
,
Black
MM
,
Casey
PH
, et al
.
Household food insecurity: associations with at-risk infant and toddler development
.
Pediatrics
.
2008
;
121
(
1
):
65
72
5
Whitaker
RC
,
Phillips
SM
,
Orzol
SM
.
Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children
.
Pediatrics
.
2006
;
118
(
3
).
6
Bitler
MP
,
Currie
J
.
Does WIC work? The effects of WIC on pregnancy and birth outcomes
.
J Policy Anal Manage
.
2005
;
24
(
1
):
73
91
7
Kowaleski-Jones
L
,
Duncan
GJ
.
Effects of participation in the WIC program on birthweight: evidence from the National Longitudinal Survey of Youth. Special supplemental nutrition program for women, infants, and children
.
Am J Public Health
.
2002
;
92
(
5
):
799
804
8
Rosenbaum
D
.
SNAP Is Effective and Efficient
.
Washington, DC
:
Center on Budget and Policy Priorities
;
2013
9
Bottino
CJ
,
Rhodes
ET
,
Kreatsoulas
C
,
Cox
JE
,
Fleegler
EW
.
Food insecurity screening in pediatric primary care: can offering referrals help identify families in need?
Acad Pediatr
.
2017
;
17
(
5
):
497
503
10
Garg
A
,
Toy
S
,
Tripodis
Y
,
Silverstein
M
,
Freeman
E
.
Addressing social determinants of health at well child care visits: a cluster RCT
.
Pediatrics
.
2015
;
135
(
2
).
11
Beck
AF
,
Henize
AW
,
Kahn
RS
, et al
.
Forging a pediatric primary care-community partnership to support food-insecure families
.
Pediatrics
.
2014
;
134
(
2
). Available at: www.pediatrics.org/cgi/content/full/134/2/e564
12
Crumley
D
,
Lloyd
J
,
Pucciarello
M
,
Stapelfeld
,
B
;
Center for Health Care Strategies
.
Addressing social determinants of health via Medicaid managed care contracts and Section 1115 demonstrations. 2018. Available at: https://www.chcs.org/resource/addressing-social-determinants-of-health-via-medicaid-managed-care-contracts-and-section-1115-demonstrations. Accessed March 18, 2019
13
MassHealth
.
MassHealth Flexible Services Program. 2018. Available at: https://www.mass.gov/files/documents/2018/11/14/MassHealth%20Flexible%20Services%20One%20Pager.pdf. Accessed January 3, 2019
14
Gormley
B.
Health care looks beyond medicine to social factors.
Wall Street Journal. September 16,
2018
. Available at: https://www.wsj.com/articles/health-care-looks-beyond-medicine-to-social-factors-1537070520. Accessed January 8, 2019
15
Kelley
T
.
Forget the pills. Healthy food is the prescription
.
Manag Care
.
2018
;
27
(
8
):
18
19
16
Center for Health Care Strategies
.
Medicaid accountable care organizations: state update. 2018. Available at: https://www.chcs.org/media/ACO-Fact-Sheet-02-27-2018-1.pdf. Accessed March 18, 2019
17
Berkowitz
SA
,
Seligman
HK
,
Meigs
JB
,
Basu
S
.
Food insecurity, healthcare utilization, and high cost: a longitudinal cohort study
.
Am J Manag Care
.
2018
;
24
(
9
):
399
404
18
Garcia
SP
,
Haddix
A
,
Barnett
K
.
Incremental health care costs associated with food insecurity and chronic conditions among older adults
.
Prev Chronic Dis
.
2018
;
15
:
E108
19
Brucker
DL
.
The association of food insecurity with health outcomes for adults with disabilities
.
Disabil Health J
.
2017
;
10
(
2
):
286
293
20
Bhargava
V
,
Lee
JS
,
Jain
R
,
Johnson
MA
,
Brown
A
.
Food insecurity is negatively associated with home health and out-of-pocket expenditures in older adults
.
J Nutr
.
2012
;
142
(
10
):
1888
1895
21
Ma
CT
,
Gee
L
,
Kushel
MB
.
Associations between housing instability and food insecurity with health care access in low-income children
.
Ambul Pediatr
.
2008
;
8
(
1
):
50
57
22
Palakshappa
D
,
Khan
S
,
Feudtner
C
,
Fiks
AG
.
Acute health care utilization among food-insecure children in primary care practices
.
J Health Care Poor Underserved
.
2016
;
27
(
3
):
1143
1158
23
Cook
JT
,
Frank
DA
,
Berkowitz
C
, et al
.
Food insecurity is associated with adverse health outcomes among human infants and toddlers
.
J Nutr
.
2004
;
134
(
6
):
1432
1438
24
Agency for Healthcare Research and Quality
.
Medical expenditure panel survey.
Available at: https://meps.ahrq.gov/. Accessed January 8, 2019
25
Machlin
SR
,
Dougherty
DD
;
Agency for Healthcare Research and Quality
.
Overview of Methodology for Imputing Missing Expenditure Data in the Medical Expenditure Panel Survey
.
Rockville, MD
:
Agency for Healthcare Research and Quality
;
2017
26
Bickel
G
,
Nord
M
,
Price
C
,
Hamilton
W
,
Cook
J
.
Guide to Measuring Household Food Security (Revised 2000)
.
Alexandria, VA
:
US Department of Agriculture
;
2013
27
Nord
MA
.
30-Day Food Scale for Current Population Survey Food Security Supplement Data
.
Washington, DC
:
US Department of Agriculture, Economic Research Service
;
2002
. Available at: https://www.ers.usda.gov/webdocs/publications/43192/31177_efan02015_002.pdf. Accessed January 24, 2019
28
Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey
.
MEPS HC-189: 2016 food security module. 2016 Available at: https://meps.ahrq.gov/data_stats/download_data/pufs/h189/h189doc.pdf. Accessed January 8, 2019
29
Hamilton
WL
,
Cook
JT
,
Thompson
WW
,
Buron
LF
,
Frongillo
EA
 Jr
,
Olson
CM
,
Wehler
CA
.
Household Food Security in the United States in 1995: Technical Report
.
Alexandria, VA
:
US Department of Agriculture
;
1997
. Available at: https://fns-prod.azureedge.net/sites/default/files/TECH_RPT.PDF. Accessed January 24, 2019
30
Agency for Healthcare Research and Quality
.
Consumer assessment of healthcare providers and systems surveys.
Available at: https://www.ahrq.gov/cahps/index.html. Accessed January 8, 2019
31
Scholle
SH
,
Vuong
O
,
Ding
L
, et al
.
Development of and field test results for the CAHPS PCMH Survey
.
Med Care
.
2012
;
50
(
suppl
):
S2
S10
32
Bethell
CD
,
Read
D
,
Stein
RE
, et al
.
Identifying children with special health care needs: development and evaluation of a short screening instrument
.
Ambul Pediatr
.
2002
;
2
(
1
):
38
48
33
National Academies of Sciences, Engineering, and Medicine
.
Accounting for Social Risk Factors in Medicare Payment
.
Washington, DC
:
The National Academies Press
;
2017
34
Partha
D
,
Norton
EC
.
Modeling health care expenditures and use
.
Annu Rev Public Health
.
2018
;
39
:
489
505
35
Suchdev
PS
,
Boivin
MJ
,
Forsyth
BW
, et al
.
Assessment of neurodevelopment, nutrition, and inflammation from fetal life to adolescence in low-resource settings
.
Pediatrics
.
2017
;
139
(
suppl 1
):
S23
S37
36
Cullen
D
,
Woodford
A
,
Fein
J
.
Food for thought: a randomized trial of food insecurity screening in the emergency department [published online ahead of print January 11, 2019]
.
Acad Pediatr
.
doi:10.1016/j.acap.2018.11.014
37
Phan
M
,
Hickey
E
,
Beck
AF
,
Klein
MD
,
Real
FJ
.
A “smart” way of addressing food insecurity in the digital age
.
Pediatrics
.
2018
;
142
(
1
):
e20181336
38
Children’s HealthWatch
.
Too hungry to learn: food insecurity and school readiness. Available at: www.childrenshealthwatch.org/wp-content/uploads/toohungrytolearn_report.pdf
. Accessed January 6, 2019
39
Connell
CL
,
Lofton
KL
,
Yadrick
K
,
Rehner
TA
.
Children’s experiences of food insecurity can assist in understanding its effect on their well-being
.
J Nutr
.
2005
;
135
(
7
):
1683
1690
40
National Center for Health Statistics
.
2015 National Health Interview Survey
.
Hyattsville, MD
:
National Center for Health Statistics
;
2016
41
Cook
JT
,
Frank
DA
,
Levenson
SM
, et al
.
Child food insecurity increases risks posed by household food insecurity to young children’s health
.
J Nutr
.
2006
;
136
(
4
):
1073
1076

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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