SNAP Participation and Medication Adherence Among Older Black Medicaid-Insured Individuals Living With Hypertension.

BACKGROUND: Black people are more likely to be diagnosed with hypertension and to experience food insecurity and antihypertensive medication non-adherence compared to White people in the U.S. The Supplemental Nutrition Assistance Program (SNAP)-a means-tested program that targets food insecurity has been shown to affect health outcomes. This study analyzed the relationship between SNAP participation and antihypertensive medication adherence among older Black Medicaid-insured individuals. METHODS: This is a retrospective cohort study using linked 2006-2014 state of Missouri Medicaid and SNAP administrative claims data. Analyses were restricted to older (≥60 years) Black individuals who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60 years with at least one pharmacy claim (n = 10,693). Our outcome measure is a dichotomous measure of antihypertensive medication adherence defined using the Proportion of Days Covered (≥80% PDC = 1). The exposure variables are four measures of SNAP participation. RESULTS: A higher proportion of SNAP participants were adherent to their antihypertensive medications compared to non-SNAP participants (43.5% vs. 32.0%). On multivariable analyses, compared to non-SNAP participants there was an increased likelihood of antihypertensive medication adherence among SNAP participants (prevalence ratio [PR] = 1.25; 95% confidence interval [CI] = 1.16-1.35). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of antihypertensive medication adherence among those who were enrolled for 10-12 months (PR = 1.41; 95% CI = 1.08-1.85). CONCLUSIONS: Medicaid-insured older Black adults who were SNAP participants had a higher likelihood of antihypertensive medication adherence compared to non-SNAP participants.

Churn in the older adult SNAP population.

Using administrative records from Missouri, we investigate the characteristics of Supplemental Nutrition Assistance Program (SNAP) participants aged 60 and older who experience administrative churn. Among these adults, 1 in 4 experienced administrative churn, and 1 in 5 experienced more than one spell of churn. Risk of churn, frequency, duration of churn spells, and the value of foregone SNAP benefits varied with individual, household, and geographic characteristics, and was more common among non-whites, members of larger households, and those living in urban areas. Our findings suggest that a significant portion of older adults experience gaps in SNAP benefit receipt.

Measuring Food Security in the United States for More Than 25 years: History, Methods, Findings, and Opportunities.

This article sets the stage for the "25 Years of Food Security Measurement: Answered Questions and Further Research" conference, with support from the Economic Research Service of the US Department of Agriculture, by providing some history of federal food security measurement, summarizing notable findings, and reviewing selected special topics in analysis methods. The federal government uses food security surveys to monitor national progress toward reducing food insecurity and to evaluate federal nutrition assistance programs. For the monitoring purpose, there is a tension between focus (on a single authoritative measurement approach) and breadth (encompassing multiple tools or instruments suitable for diverse populations, contexts, and applications). For the program evaluation purpose, challenges include coordination with study designs capable of real causal estimation in the face of strong self-selection effects and tailored reference periods in survey questions that match the timing of program participation. Some analysis methods treat the food security survey items as distinct experiences of hardship, whereas others treat the food security survey items as windows on an underlying latent variable, a food insecurity score. The severity of food-related hardship may be assessed quantitatively by the number of distinct hardships reported, by the estimated value of a latent food insecurity score, or by the frequency of occurrence for sentinel hardships. Ongoing work investigates statistical approaches that are sufficiently simple for policy application and yet sufficiently flexible to accurately match the empirical survey evidence.

Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension.

BACKGROUND: Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear. OBJECTIVE: To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals. DESIGN: Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data. PARTICIPANTS: Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60. MAIN MEASURES: The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern. KEY RESULTS: On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (ß = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (ß = 0.44, S.E. = 0.041). CONCLUSIONS: Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.

Hypertension, Diabetes and Medication Adherence among the Older Supplemental Nutritional Assistance Program Population.

The burdens of chronic diseases such as hypertension and diabetes for older Americans are profound. Yet, data on the population-level prevalence of hypertension and diabetes among the older adult Supplemental Nutritional Assistance Program (SNAP) population and the associated level of medication adherence is lacking despite evidence of the "treat or eat" trade-off in the general population. We used linked administrative data from SNAP and Medicaid between 2006 and 2014 in the state of Missouri to document rates of hypertension or diabetes diagnoses and medication adherence. About 69% of the study sample were found to be diagnosed with a hypertension and 40% with diabetes. Approximately 1 in 4 of those living with hypertension and 1 and 3 of those living with diabetes were nonadherent to antihypertensive or antidiabetic medications each year, on average. Furthermore, medication non-adherence increases with age and is more common among non-White and urban residents.

Giving kids a boost: The positive relationship between frequency of SNAP participation and Infant's preventative health care utilization.

Well-child visits are protective for child health but underutilized in the United States. The Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program in the United States, has been shown to reduce food insecurity and may also promote child health by supporting preventative health care utilization. We examined the relationship between SNAP participation and infant well-child visits using state administrative data from Missouri's Department of Social Services for the period January 2006 to July 2014 for more than 50,000 infant-mother dyads. We find that compared to always receiving SNAP, leaving SNAP or receiving SNAP unstably reduces the likelihood that an infant receives all recommended well-child visits in the first year. These patterns are more pronounced for infants living in urban areas, infants with Black or Hispanic mothers, and infants whose mothers are diagnosed with depression. We also find that stable SNAP participation primarily influences vaccination rates through well-child visits, which is when most infants receive their immunizations. Given the increased public health risk of foregone care, these results may inform policy makers as they consider making permanent policy waivers to reduce the administrative burden of the recertification process and increase the stability of SNAP participation.

Childhood injuries and food stamp benefits: an examination of administrative data in one US state.

BACKGROUND: Currently in the United States, childhood injuries are the leading cause of mortality and morbidity, resulting in an estimated 9.2 million emergency department visits and $17 billion annually in medical costs. For preschoolers, it is also the leading cause of disability. METHODS: We use linked administrative data for SNAP and Medicaid in Missouri from January 2010 to December 2013 to explore monthly patterns in the association between SNAP receipt and ER claims due to childhood injury for children age 0-5 and to examine if these patterns are sensitive to the timing of SNAP benefits. We chose the state of Missouri because unlike most states that disburse SNAP benefits within the first 10 days of the calendar month, Missouri pays SNAP benefits between the first twenty-two days of the month, based on the recipient's birthdate and last name. RESULTS: SNAP benefits received later in the calendar month are associated with reductions in ER claims for childhood injuries. Furthermore, the final week in the SNAP benefit month is associated with an increase in ER claims for childhood injuries. CONCLUSION: In terms of public policy, our results suggest that having SNAP disbursement later in the month may have benefits for households.

Improving Teacher Practices With Children Under Five: Experimental Evidence From the Mississippi Buildings Blocks.

BACKGROUND: The literature on the effects of teacher coaching in early childhood (EC) education programs is underdeveloped but emerging. Using the theory of action in professional development as our theoretical framework, we hypothesize that active coaching improves teaching methods and creates a more effective classroom environment for enhancing children's learning and skills. OBJECTIVES: This study evaluates the effects of the Mississippi Building Blocks (MBB) program, an EC intervention with a strong emphasis on supervisor and coaching training. RESEARCH DESIGN: We conduct a randomized controlled experiment in which data were collected at baseline, midpoint (Month 3), and postintervention (Month 6) in 24 preschool classrooms in Mississippi. SUBJECTS: The experiment included 195 preschoolers, of which 95 were in classrooms led by teachers who received coaching (treatment) and 100 were in classrooms without coaching (control). MEASURES: We measured child's emergent language and literacy, fine motor skills, gross motor skills, print language skills, problem-solving, math skills, and socioemotional development. RESULTS: We find that MBB coaching led to substantial improvements in child outcomes relative to the control group, particularly in gross motor skills, print language skills, and socioemotional development. We also find some evidence that MBB coaching improved math skills, though these estimates are on the margin of statistical significance. Finally, a mediator analysis indicates that improvements in the classroom learning environment brought about by MBB coaching improved child outcomes. CONCLUSIONS: Our findings suggest that an intensive form of classroom coaching for teachers leads to significant gains in child outcomes.

Dosage Effects in the Child-Parent Center PreK-to-3rd Grade Program: A Re-Analysis in the Chicago Longitudinal Study.

Although substantial investments in early childhood intervention have continued, whether gains are sustained past kindergarten for routinely implemented programs is a critical research need. Using data from the Chicago Longitudinal Study (CLS; N=1,539; 50.3% female; 92.9% African American and 7.1% Hispanic), an on-going investigation of the Child-Parent Center (CPC) program for an inner-city cohort, this study investigates the effects of program duration from preschool to 3rd grade on school outcomes and whether the effects differ by gender. Regression analyses are conducted to compare the differences in outcomes among intervention groups. Inverse probability weighting (IPW) is used to adjust for potential attrition and selection biases. Findings indicate that relative to the preschool plus kindergarten (P-K) group, participation from preschool through third grade (P-3) is significantly associated with better academic functioning at both 3rd and 8th grades, better classroom adjustment at 3rd grade, lower rates of retention and school mobility, and few years of special education. Relative to the preschool through second grade (P-2) group, the P-3 group has significantly higher academic functioning in third grade. Results suggest that the P-3 dosage is associated with larger effects on academic functioning for girls and larger effects on social-emotional functioning for boys compare to the P-K dosage. Findings suggest that receiving up to third grade (P-3) of an early childhood education program have associated with persistent effects on developmental outcomes compared to the dosages of P-K. Multi-year programs have the potential to sustain early childhood gains and promote healthy development via improving academic functioning and school experiences.

SNAP benefits and childhood asthma.

Anecdotal and descriptive evidence has led to the claim that some low-income households may face a "eat or breathe" tradeoff, but quantitative evidence is scarce. We link Medicaid claims data to monthly Supplemental Nutritional Assistance Program (SNAP) participation data from the state of Missouri from 2010 to 2013 to explore monthly patterns in children's emergency room (ER) claims for asthma and to examine whether these patterns are sensitive to the timing and amount of SNAP benefits. This allows us to empirically test whether SNAP households with Medicaid insurance face trade-offs between food and medicine that increases the likelihood that a child in a SNAP and Medicaid household will go to the ER for asthma at the end of the month. While we do not find overwhelming evidence that the timing of SNAP benefits receipt are associated with the timing of asthma-related ER visits, we do find clear evidence that increased SNAP benefits are associated with a reduction in the overall probability of an asthma-related ER visit.

Decomposing the Household Food Insecurity Gap for Children of U.S.-Born and Foreign-Born Hispanics: Evidence from 1998 to 2011.

Using the Early Childhood Longitudinal Study-K, multivariate analysis, state fixed effects, and regression decomposition, we examine changes in food insecurity for Hispanic kindergarteners between 1998 and 2011, a time period of rapid immigration and political/socio-economic changes. During this time the household food insecurity gap between children of U.S.-born and foreign-born mothers increased by almost 7 percentage points. The factors-child, family, and state-that contributed to the nativity gap differed over time. In both periods, lower familial resources among immigrant families, i.e. endowment effects, contributed to the gap; this was the main component of the gap in 2011 but only one component in 1998. In 1998, heterogeneity in state effects was positively associated with the nativity food insecurity gap. This means that children of foreign-born mothers experience higher household food insecurity than do children of U.S.-born mothers in the same state, even after controlling for child and family characteristics. In 2011, almost half of the gap remained unexplained. This unexplained portion could be driven by differential effects of the Great Recession, growing anti-immigrant sentiment, and/or the relatively large share of unauthorized immigrants in 2011.

One Year of Preschool or Two - Is It Important for Adult Outcomes? Results from the Chicago Longitudinal Study of the Child-Parent Centers.

Until the last year, public funding for preschool education had been growing rapidly over a decade with most state programs providing one year of preschool for four year olds. Fewer three year olds are enrolled in preschool. To investigate the importance of enrollment duration, this study is the first to estimate long-term dosage effects of years of preschool. We use data from a cohort of 1,500 students in the Chicago Longitudinal Study who enrolled in the Chicago Public Schools in the mid-1980s. Many of these students participated in a high-quality preschool program called Child-Parent Centers (CPC) for one or two years. To address selection with multiple treatments, we employ inverse propensity score weighting. Relative to children who attended one year of CPC preschool, the two-year group is significantly less likely to receive special education or be abused or neglected or to commit crimes. The findings provide support for the long-term benefits of greater exposure to preschool.

School-based early childhood education and age-28 well-being: effects by timing, dosage, and subgroups.

Advances in understanding the effects of early education have benefited public policy and developmental science. Although preschool has demonstrated positive effects on life-course outcomes, limitations in knowledge on program scale, subgroup differences, and dosage levels have hindered understanding. We report the effects of the Child-Parent Center Education Program on indicators of well-being up to 25 years later for more than 1400 participants. This established, publicly funded intervention begins in preschool and provides up to 6 years of service in inner-city Chicago schools. Relative to the comparison group receiving the usual services, program participation was independently linked to higher educational attainment, income, socioeconomic status (SES), and health insurance coverage, as well as lower rates of justice-system involvement and substance abuse. Evidence of enduring effects was strongest for preschool, especially for males and children of high school dropouts. The positive influence of four or more years of service was limited primarily to education and SES. Dosage within program components was mostly unrelated to outcomes. Findings demonstrate support for the enduring effects of sustained school-based early education to the end of the third decade of life.

Low Birth Weight, Preschool Education, and School Remediation.

Studies have documented a strong relationship between low birth weight status and adverse child outcomes such as poor school performance and need for special education services. Following a cohort of over 1,300 low-income and predominately African American children in the Chicago Longitudinal Study we investigated whether birth weight and family socio-economic risk measured at the time of the child's birth predicts placement into special education classes or grade retention in elementary school. Contrary to previous research, we found that low birth weight (< 5 ½ pounds) does not predict special education placement. Rather, these children (especially boys) were more likely to be retained in grade as an alternative approach to addressing poor school performance. Family socio-economic risk at birth was a significant predictor of the need for remedial services. We also assessed whether a high-quality preschool program offered at ages 3 and 4 can reduce the negative effects of low family SES and birth weight on the need for special education and grade retention. Preschool participation in the Child-Parent Centers was found to reduce the likelihood of school remediation. The effects of preschool were greater for children from families with higher levels of socio-economic disadvantage. The beneficial effects of preschool on special education placement were also larger for boys than girls.

Childhood Predictors of Adult Substance Abuse.

Identification of the early determinants of substance abuse is a major focus of life course research. In this study, we investigated the child, family, and school-related antecedents of the onset and prevalence of substance abuse by age 26 for a cohort of 1,208 low-income minority children in the Chicago Longitudinal Study. Data onon well-being have been collected prospectively since birth from administrative records, parents, teachers, and children. Results indicated that the prevalence of substance abuse by age 26 was 32 percent (self reports or criminal justice system records) with a median age of first use of 17. Probit regression analysis indicated that substance abuse prevalence was primarily determined by gender (males had a higher rate), trouble making behavior by age 12, school mobility, and previous substance use. Family and peer predictors included involvement in the child welfare system by age 9, parent expectations for school success at age 9, parent substance abuse by children's age 15, and deviant peer affiliation by age 16. Age of first substance use was predicted by gender and race/ethnicity (males and Blacks had earlier incidence), involvement in the child welfare system, and family risk status at age 8. As with prevalence, the pattern of predictors for males was similar to the overall sample but the magnitude of effects was stronger.. The predictors of the timing of substance use dependency were gender, family conflict by age 5, involvement in the child welfare system, social maturity at age 9, adolescent school mobility, and school dropout by age 16. Findings indicate that the promotion of family involvement and positive school and social behavior can reduce the risk of substance abuse.