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Food Insecurity Is Prevalent in Iowa’s Medicaid Expansion Population



      Food insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations.


      Our objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa’s Medicaid expansion population.


      We conducted a cross-sectional telephone survey between March and May of 2019.


      Our sample was drawn from Medicaid members enrolled in Iowa’s expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample.

      Main outcome measure

      Our main outcome was whether a respondent’s household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool.

      Statistical analyses performed

      We weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors.


      The estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity.


      Our findings show that food insecurity is prevalent in Iowa’s Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access.


      Iowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP)



      Iowa Wellness Plan (IWP) (Federal Poverty Level (FPL)), Healthy Behavior Program (HBP) (Supplemental Nutrition Assistance Program (SNAP))
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        • Allen S.M.
        • Croke A.L.
        • Felt-Lisk S.
        • et al.
        The faces of Medicaid: The complexities of caring for people with chronic illnesses and disabilities. Princeton (NJ): Center for Health Care Strategies, Inc.; 2000.
        • Sorace J.
        • Wong H.H.
        • Worrall C.
        • et al.
        The complexity of disease combinations in the Medicare population.
        Popul Health Manag. 2011; 14: 161-166
      1. Center for Medicaid and CHIP Services, Division of Quality and Health Outcomes. Medicaid and CHIP Beneficiary Profile. Baltimore: Centers for Medicare & Medicaid Services; 2020.
        • Alley D.E.
        • Asomugha C.N.
        • Conway P.H.
        • et al.
        Accountable health communities addressing social needs through Medicare and Medicaid.
        N Engl J Med. 2016; 374: 8-11
        • Rediger K.
        • Miles D.R.B.
        Clinical-community partnerships to reduce food insecurity among high-need, high-cost Medicaid patients.
        Ann Intern Med. 2018; 169: 490-491
        • National Quality Forum
        A framework for Medicaid programs to address social determinants of health: Food insecurity and housing instability. Washington, DC: National Quality Forum; 2017.
        • Coleman-Jensen A.
        • Rabbitt M.P.
        • Gregory C.A.
        • et al.
        Household food security in the United States in 2018. Washington: US Department of Agriculture, Economic Research Service; 2019 September. ERR-270.
        • Garfield R.
        • Rudowitz R.
        • Orgera K.
        • et al.
        Understanding the intersection of Medicaid and work: What does the data say?. San Francisco, CA: Kaiser Family Foundation; 2019.
        • Londhe S.
        • Ritter G.
        • Schlesinger M.
        Medicaid expansion in social context: Examining relationships between Medicaid enrollment and county-level food insecurity.
        J Health Care Poor Underserved. 2019; 30: 532-546
        • Himmelstein G.
        Effect of the Affordable Care Act’s Medicaid expansions on food security, 2010-2016.
        Am J Public Health. 2019; 109: 1243-1248
        • Leung C.W.
        • Epel E.S.
        • Ritchie L.D.
        • et al.
        Food insecurity is inversely associated with diet quality of lower-income adults.
        J Acad Nutr Diet. 2014; 114: 1943-1953
        • Gundersen C.
        • Ziliak J.P.
        Food insecurity and health outcomes.
        Health Aff (Millwood). 2015; 34: 1830-1839
        • Chapel J.M.
        • Ritchey M.D.
        • Zhang D.
        • et al.
        Prevalence and medical costs of chronic diseases among adult Medicaid beneficiaries.
        Am J Prev Med. 2017; 53: S143-S154
        • Pheley A.M.
        • Holben D.H.
        • Graham A.S.
        • et al.
        Food security and perceptions of health status: A preliminary study in rural Appalachia.
        J Rural Health. 2002; 18: 447-454
        • Stuff J.E.
        • Casey P.H.
        • Szeto K.L.
        • et al.
        Household food insecurity is associated with adult health status.
        J Nutr. 2004; 134: 2330-2335
        • Berkowitz S.A.
        • Seligman H.K.
        • Choudhry N.K.
        Treat or eat: Food insecurity, cost-related medication underuse, and unmet needs.
        Am J Med. 2014; 127: 303-310
        • Herman D.
        • Afulani P.
        • Coleman-Jensen A.
        • et al.
        Food insecurity and cost-related medication underuse among nonelderly adults in a nationally representative sample.
        Am J Public Health. 2015; 105: e48-e59
        • Gundersen C.
        • Kreider B.
        • Pepper J.V.
        Partial identification methods for evaluating food assistance programs: a case study of the causal impact of SNAP on food insecurity.
        Am J Agric Econ. 2017; 99: 875-893
        • Schmidt L.
        • Shore-Sheppard L.
        • Watson T.
        The effect of safety-net programs on food insecurity.
        J Hum Resour. 2016; 51: 589-614
        • Swann C.A.
        Household history, SNAP participation, and food insecurity.
        Food Policy. 2017; 73: 1-9
        • Zoellner J.
        • You W.
        • Connell C.
        • et al.
        Health literacy is associated with healthy eating index scores and sugar-sweetened beverage intake: Findings from the rural Lower Mississippi Delta.
        J Am Diet Assoc. 2011; 111: 1012-1020
        • Begley A.
        • Paynter E.
        • Butcher L.M.
        • et al.
        Examining the association between food literacy and food insecurity.
        Nutrients. 2019; 11: 445
        • Raskind I.G.
        Hunger does discriminate: Addressing structural racism and economic inequality in food insecurity research.
        Am J Public Health. 2020; 110: 1264-1265
        • Askelson N.M.
        • Wright B.
        • Brady P.J.
        • et al.
        Implementation matters: Lessons from Iowa Medicaid’s healthy behaviors program.
        Health Aff (Millwood). 2020; 39: 884-891
        • Hager E.R.
        • Quigg A.M.
        • Black M.M.
        • et al.
        Development and validity of a 2-item screen to identify families at risk for food insecurity.
        Pediatrics. 2010; 126: e26-e32
        • Gundersen C.
        • Engelhard E.E.
        • Crumbaugh A.S.
        • Seligman H.K.
        Brief assessment of food insecurity accurately identifies high-risk US adults.
        Public Health Nutr. 2017; 20: 1367-1371
        • Washington, Wyoming, Alaska, Montana, Idaho Rural Health Research Center
        RUCA Data ZIP Code RUCA Approximation; Seattle (WA): WWAMI Rural Health Research Center.
        • Kessler R.C.
        • Barber C.
        • Beck A.
        • et al.
        The world health organization health and work performance questionnaire (HPQ).
        J Occup Environ Med. 2003; 45: 156-174
        • Agency for Healthcare Research and Quality
        Adult Medicaid Survey 5.0. Updated October 2020.
        • Morris N.S.
        • MacLean C.D.
        • Chew L.D.
        • Littenberg B.
        The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading ability.
        BMC Family Practice. 2006; 7: 1-7
        • American Association for Public Opinion Research
        Standard definitions: Final dispositions of case codes and outcome rates for surveys [Internet]. Washington, DC: AAPOR. 2015.
        • NORC at the University of Chicago
        Final report: Methodology report: 2014–2015 Nationwide CAHPS Survey of Adults Enrolled in Medicaid between October and December, 2013.
        • Venkataramani A.S.
        • Bair E.F.
        • Dixon E.
        • et al.
        Assessment of Medicaid beneficiaries included in community engagement requirements in Kentucky.
        JAMA Netw Open. 2019; 2: e197209
        • Sommers B.D.
        • Goldman A.L.
        • Blendon R.J.
        • Orav E.J.
        • Epstein A.M.
        Medicaid work requirements—results from the first year in Arkansas.
        N Engl J Med. 2019; 381: 1073-1082
        • Berkowitz S.A.
        • Basu S.
        • Gundersen C.
        • et al.
        State-level and county-level estimates of health care costs associated with food insecurity.
        Prev Chronic Dis. 2019; 16: E90
        • Spencer A.
        • Freda B.
        • McGinnis T.
        • et al.
        Measuring social determinants of health among Medicaid beneficiaries: Early state lessons. Hamilton, NJ: Center for Health Care Strategies, Inc.; 2016.
        • North Carolina Institute of Medicine
        Metrics to Drive Improvements in Health: A Report of the Task Force on Health Care Analytics. Morrisville, NC: North Carolina Institute of Medicine; 2017.
        • Carroll A.E.
        The problem with work requirements for Medicaid.
        JAMA. 2018; 319: 646-647
        • Askelson N.M.
        • Brady P.
        • Wright B.
        • et al.
        Purged from the rolls: A study of Medicaid disenrollment in Iowa.
        Health Equity. 2019; 3: 637-643
        • Fraze T.K.
        • Brewster A.L.
        • Lewis V.A.
        • et al.
        Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by US physician practices and hospitals.
        JAMA Netw Open. 2019; 2: e1911514
        • Amarashingham R.
        • Xie B.
        • Karam A.
        • et al.
        Using community partnerships to integrate health and social services for high-need, high-cost patients. The Commonwealth Fund; 2018.
        • Joshi K.
        • Smith S.
        • Bolen S.D.
        • et al.
        Implementing a produce prescription program for hypertensive patients in safety net clinics.
        Health Promot Pract. 2019; 20: 94-104


      P. J. Brady is a graduate research assistant, Department of Community and Behavioral Health, University of Iowa College of Public Health, and the University of Iowa Public Policy Center, Iowa City, IA.


      N. M. Askelson is an assistant professor, Department of Community and Behavioral Health, University of Iowa College of Public Health, and a research fellow, University of Iowa Public Policy Center, Iowa City, IA.


      B. Wright is an associate professor, Department of Family Medicine, University of North Carolina School of Family Medicine, Chapel Hill, NC.


      E. Daly is a graduate research assistant, Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, IA.


      E. Momany is a senior research scientist, University of Iowa Public Policy Center, Iowa City, IA.


      B. McInroy is a research associate, University of Iowa Public Policy Center, Iowa City, IA.


      P. Damiano is a director and research fellow, University of Iowa Public Policy Center, Iowa City, IA.