Challenging Dogma

...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

Striving to Improve the Nutritional Status of the Nation’s Low-Income households: The Need for a Change in Distribution of Food Stamps - Sarah Nasta

Food Stamps – Where We Started and Where We Are Today

As public health practitioners and clinicians, we know that proper nutrition is a key component to maintaining good health status. Access to an adequate amount of food is essential for the prevention of disease and maintaining a healthy, active lifestyle. The national Food Stamp program was originally developed as a means to distribute surplus food to low-income families during 1939 and the early 1940’s. In the four years of the original food stamp program it served approximately 20 million people, in almost every county of the United States. The program came to an end in 1943 when “the conditions that brought the program into being – unmarketable food surpluses and widespread unemployment – no longer existed” (5). The end of the nation’s food stamp program marked the end of the Great Depression and the beginning of World War II.

In the early 1960’s a pilot program was implemented to try and reignite the food stamp program; it became permanent on August 31, 1964. Until 1977 households had to purchase their food stamps. For every dollar an individual paid they received a government set equivalent in food stamps to be used at grocery stores for purchasing food products, excluding the purchase of alcohol and imported foods (5). The program is funded at the federal level but distributed and regulated at the state level. This division of power unfortunately allows for discrepancies in program implementation. In Massachusetts for example, 57 percent of households eligible for food stamps do not receive then, as compared to 41 percent nationally (3).

In 1993 the government began to allow programs to test the use of an EBT (electronic benefit transfer) card for the purchasing of food stamp products rather than actual paper stamps. This was to help relieve some of the costs associated with the implementation of the food stamp program. Every state was mandated to implement the use of these cards by October 1, 2002. In 2004 the food stamp program helped to provide food for 10.3 million households and 23.9 million individuals each day (5).

Despite these impressive numbers there is still a major problem of food insecurity and food shortage in the United States. In 2003 it was estimated that approximately 30 million people in the United States go hungry each year (2). This number illustrates that we as a country are a long way from promoting the nutritional well-being that as public health professionals we champion.

To be effective in promoting proper nutrition and eliminating the hunger disparities that currently exist in the United States, public health needs to focus on promoting the food stamp program as a community outreach program rather than a daunting government administered service. The public health community needs to address hunger issues from the perspective of the families who are suffering, and the parents who are discouraged and embarrassed because at the end of the month they cannot provide food for their children.

Currently, people in America are facing hard times and hard choices. Public health needs to ask itself this question: which is more important, allowing a government run, bureaucratic agency to continue maintaining its strict regulations on who is and is not allowed to access food stamps, or is it providing access to public services so people can eat and afford to heat their homes at the same time? We need to begin focusing our efforts so families are not forced to choose between the two.

Shifting the Health Focus from the Future to the Present

Currently, one of the main health focuses in the United States for many public health practitioners is the prevention of disease in the future. While this preventative approach is extremely important and deserves a great deal of attention from the public health community; the focus has been lost from public health access issues facing people here in the present. While the main nutritional focus of the public health community has shifted toward obesity prevention and the problems associated with over consumption of food, 10% of American families experienced food insecurity and hunger in 1999 and 2000 (4). While it has been demonstrated that there are well documented health risks associated with being overweight or obese, public health professionals have lost sight of the problems associated with malnourishment and the long term health problems that can arise from this situation.

Food insecurity exists when “the availability of nutritionally adequate and safe foods or the ability to acquire foods in socially acceptable ways is limited or uncertain.” Food insecurity is a risk factor for many health implications and has been shown to be associated with overweight in women, poor health status among children, negative academic and psychosocial outcomes in children, and with individuals having higher odds of reporting poor health and suffering from depression and distress (4).

Households headed by a single female with children, and all other households with children, experience food insecurity at rate higher than the national average as reported by the 2000 Current Population Survey administered by the US Census Bureau. In the same survey it was reported that of the households that met the federal poverty level requirement for food stamp eligibility, approximately 47% of single female-headed households and 42% of households with children experienced food insecurity (4). These numbers illustrate that the food stamp program is missing many of the households that need its services and that although government programs for food assistance are being accessed, food insecurities still exist.

In California, and more specifically Los Angeles County, a study revealed that among food pantry recipients, 90% were living well below the poverty level, 44% were homeless, but only 15% of these individuals were receiving food stamps. In 2001, 1.46 million California adults had incomes below 130% of the poverty level and experienced food insecurity; however 1.21 million people were not receiving food stamp benefits. The study states that even more recent statistics illustrate that half of eligible individuals are not receiving benefits. In California, and Los Angeles, barriers to program participation include a lack of knowledge about program eligibility, a lengthy and complex application process, and a finger imaging requirement (1). The results of the study showed that households with younger, single parents and those with better English language abilities were more likely to use food stamps (1).

Homelessness and limited English speaking abilities act as barriers to participation in food stamp programs. The lack of a permanent address prohibits many homeless individuals from accessing food stamp benefits even though they are a segment of the population that needs more help than many others. Undocumented immigrants with limited English language abilities comprise a large portion of food pantry recipients who are not receiving food stamps in Los Angeles although the problem is not unique to this particular area. Undocumented immigrants are ineligible for food stamp benefits; however, if their children were born in the United States they are U.S. citizen and area in fact eligible for food stamp benefits. Because of the language barrier and fear of what documents they will be asked to present, many undocumented immigrants do not apply for food stamps even though the regulations say that if they are applying on behalf of a child they do not have to present any documentation on themselves.

Government Procedures – Challenging Social Cognitive Theory and Self-Efficacy

A person’s ability to provide for their family is very important to their feeling of self-efficacy. Not being able to afford food for yourself and your children can be a very difficult situation for many people to handle. Self-efficacy differs from a person’s self-esteem, which deals with their feelings of self-worth. Self-efficacy is a person’s impression that they are capable of attaining certain goals and/or of performing certain behaviors. Whether true or not, it is a person’s belief that they have the means to produce a certain effect, to manage a certain situation, or a potential situation (6).

Dealing with the government agencies needed to apply for food stamps can be a very difficult, daunting, and confusing experience. In Boston, people are shuffled between buildings when their questions cannot be answered and are constantly asked to present unnecessary or excessive documentation to prove that they meet eligibility requirements. Being denied assistance can be very damaging to a person’s self-efficacy because the government has said that they will not help them, yet regardless of this outcome people still cannot afford to properly feed their families and pay their bills.

Families need to fill out an enormous amount of forms to prove that they are eligible for any type of assistance. In Franklin County, Ohio people need to declare that they are in a state of severe poverty in order to be eligible. Families are penalized for any type of minimal asset they acquire that could be used as financial cushion. It requires a 35-page form in order to make just the declaration. The majority of workers in the welfare system are paid to make sure that all of the innate rules are followed to the letter while very few are assigned to helping people become self-sufficient once again and get out of the welfare system (7).

If an individual applies for food stamps and is denied the first time, they are far less likely to be persistent and try again even though the need for assistance still exists. The difference between being awarded or denied food assistance could be as simple as filing one additional form, but if a person does not believe that they will be successful they may not have the persistence to find out why they were denied.

Once a family is on food stamps it can still be damaging to a person’s self-efficacy. Too often, the amount awarded to families is not enough to adequately feed a family or feed them with proper, nutritious foods. In Oregon, the governor decided to live a week on food stamps and the foods that he could purchase with them. The governor had exactly $21 to buy a week’s worth of food at the grocery store, the same amount the state’s average food stamp recipient spends a week. Rather than being able to buy his usual Progresso soups, at $1.53 a can, he instead had to purchase Cup O’Noodles for $0.33 and generic peanut butter. He spent a total of $20.97 on 19 items after having to give back one of the Cup O’Noodles and two bananas. This experiment just shows how difficult it can be to feed an individual on food stamps if you can manage to navigate your way through the system first (8).

The lengthy process is also wearing on a person’s motivation. Their financial situation most likely causes a great deal stress in their daily life and if they hear of another person’s bad experience with the food stamp program, or the Department of Transitional Services in general, then they are less likely to be motivated to advocate on their own family’s behalf. Many people don’t want to admit to themselves that they cannot afford to feed their families. Until they can admit this to themselves they cannot build up the confidence needed to do something to rectify the situation. The government’s bureaucracy and harsh nature does not help with this process.

The Future of Food Stamp Assistance

Large government agencies that are designed to deal with populations on a large scale basis are not adequately equipped to deal with people on a personal level and are not capable of devoting the time needed for individualized client attention. Food stamps, as well as other government food and income assistance programs, need to be advocated to individuals at a community level, with a closer directive aimed toward individual people and their personal situations. In order to build up someone’s feeling of self-efficacy they need to feel that the steps they are taking are actually doing something to help better the situation rather than surrendering to their current circumstances.

Many people view accessing welfare and the benefits associated with this program in a negative light. Over many years the welfare program has gained a negative social stigma, with an attitude that people accessing its services are lazy and cannot help themselves. The program has made at least one progressive step in relieving the burden of social stigma however, with the implementation of the EBT cards. The card resembles a debit card that people use for everyday purchases, relieving the obvious nature and shame associated with using paper stamps.

To increase program awareness and the number of families and individuals accessing the food stamp benefits, public health professionals should strive to bring this program into communities at an individual level. This begins with holding community education sessions at neighborhood health centers or churches to inform people of the benefits that are available, how to properly navigate the system, and compile all of the documentation they will be asked to present.

This process has already begun in several states, but it needs to continue to expand and eventually take on a new form. In Massachusetts for example, an agency has emerged whose purpose is to assist families in obtaining the basic things needed to promote proper health in children of low-income families, such as proper housing, food, heat and hot water, and education. The Medical-Legal Partnership for Children at Boston Medical Center is a small team of lawyers who work with pediatricians to ensure that the patients of BMC are receiving these necessities. Patients of the pediatrics department at Boston Medical Center or one its outlying clinics are referred to the MLPC by their providers or a social worker. The lawyers at the partnership then attempt to help the patients’ families navigate government systems to obtain the benefits they are entitled to.

One service they provide is help obtaining proper food stamps benefits. Families who are screened by their doctors and show problems affording food, have already applied for food stamps but have been denied, or were cut-off from their benefits are referred to the Medical-Legal Partnership and the employees there help the renegotiate their benefits. There have been numerous cases in which clients have been denied because the Department of Transitional Assistance worker asked for unnecessary paperwork, was unavailable to answer a client’s questions so they were confused about what paperwork they needed to turn in, or the DTA did not provide the proper interpreter at a meeting or translate an important letter into the client’s language.

The Medical-Legal Partnership is a revolutionary organization that combines the fields of medicine and law to prevent negative health outcomes in children and their families. While this is a very progressive outlook on public health it can only go so far. The staff has limitations on the number of cases they can handle at one time due to a lack of man power, client families must also have a child who is a patient at Boston Medical Center. There are many families in Massachusetts and other states who could benefit greatly from these services but receive their health care at a facility that does not have a program such as this or cannot afford health care. To help the families who have not been reached by a service such as this, the public health community, in cooperation with the medical community, needs to develop a broader community outreach program that can reach a wider range of families.

This outreach can begin at community health centers or local churches. Once a month, or once every other week, a representative from the local public health commission or a social worker could conduct an educational workshop to inform families of the eligibility criteria for programs such as food stamps. The workshops could also include information pertaining to which documents are required for certification, how often you need to recertify, and individual’s rights regarding the receipt of government benefits. These outreach workers could also help to reassure undocumented parents that they can apply for assistance on behalf of their citizen children without jeopardizing their status in the United States. There are too many families not receiving assistance because of fear of being deported. Another agency that should be involved in this outreach is the DTA itself. A supervisor from the local branch could also attend these sessions to help eliminate any misconceptions people have developed over the years with regards to the system and its workers.

The national food stamp program is a public welfare program developed to help people afford proper food for themselves and their families. Although it has reached many families over the years, there is still a large gap in the services provided and many individuals go without help. To help lower the percentage of impoverished families experiencing food insecurities, public health professionals need to develop community education initiatives to educate people on the techniques of navigating the complex agencies of our government. We also need to develop an advocacy system to ensure that people who qualify for benefits receive them and at the proper amounts.

Resources Used:
  1. Algert, S.J., Reibel, M. & Renvall, M.J. Barriers to Participation in the Food Stamp Program among Food Pantry Clients in Los Angeles. American Journal of Public Health. May 2006; 96(5), 807-809.

2. CBS Evening News. Food Shortage in the Homeland: Handout lines getting longer as supplies are drying up. June 10, 2003. Accessed April 3, 2007.

3. Massachusetts Citizens for Children. Accessed April 18, 2007.

4. Oberholser, C.A. & Tuttle, C.R. Assessment of Household Food Security among Food Stamp Recipients. American Journal of Public Health. May 2004; 94(5), 790-95.

5. US Department of Agriculture: Food and Nutritional Service. Food Stamp Program. Accessed April 3, 2007.

6. Self-efficacy. Accessed April 4, 2007.

7. Walters, J. Busting the Welfare Bureaucracy. Governing. March 1997. 19-23.

8. Silverman, J. Oregon governor starts week on food stamps. Yahoo News. Accessed April 25, 2007.

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