Incorporating Referrals to WIC and SNAP in Health Care System Settings

The US Department of Agriculture Food and Nutrition Service provides 2 of the largest programs to support infants, children, and families living in low-income households: the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP). Both WIC and SNAP work synergistically to provide critical services that improve child health and reduce food insecurity, which has been rising among households with children and will likely continue to rise.1–3 Despite rising food insecurity, many eligible children and families do not participate in these programs.4,5 While national organizations recommend pediatricians connect patients with WIC and SNAP, there are barriers to widespread implementation of this recommendation. In this feature, we provide a broad overview of WIC and SNAP, recommend incorporating health care system referrals to these programs, and suggest advocacy opportunities in the face of anticipated policy changes.WIC connects families with nutritious foods, nutrition education, breastfeeding support, and community resources, including health care, for pregnant and postpartum individuals, infants, and children aged less than 5 years living in low-income households.6 As of 2023, approximately half of US infants and children and more than one-third of pregnant people were eligible to participate in WIC.4 WIC participation is associated with lower risks of preterm birth, low birth weight, and infant mortality as well as higher diet quality and improved cognitive outcomes in early childhood, with durable participation associated with better outcomes.3,7,8 On a systems level, changes to WIC packaging have been associated with positive changes in the food environment in low-income neighborhoods and may be cost-effective in preventing development of childhood obesity.9,10 Despite these benefits, only 56% of eligible people participate in WIC, also known as the coverage rate. Infants have the smallest gap between eligibility and participation, with 82% coverage rate, while participation of children aged 1 through 4 years decreases stepwise by year, with 67% of eligible 1-year-olds but only 27% of eligible 4-year-olds participating.4 Coverage rates vary by race and ethnicity: Hispanic/Latino individuals have the highest rate at 66%, followed by 53% for non-Hispanic Black and 49% for non-Hispanic white, Asian, multiracial, and Hawaiian/Pacific Islander groups. Non-Hispanic American Indian/Alaska Native individuals have the lowest coverage rate at 47%.4SNAP provides monthly funds to families with low incomes to help them buy food.11 SNAP participation is associated with improved well-child visit attendance and vaccination rates and reduced food insecurity.2,12 Participating children and families are less likely to report needing but not being able to afford health care services or dental visits.13 Recent data show that SNAP served 88% of eligible households nationwide and that almost 80% of households receiving SNAP included either a child aged less than 18 years, an older adult, or an individual with a disability. Nearly 40% of SNAP participants were children, and the majority (71%) were school-aged. Thirty-five percent of participants were non-Hispanic white, 26% non-Hispanic Black, 16% Hispanic, 4% non-Hispanic Asian, and 1% non-Hispanic American Indian/Alaska Native.14 Despite the benefits of SNAP, many households remain unenrolled. SNAP enrollment varies regionally, with the highest SNAP coverage rates in the Midwest region and the lowest in the Southwest region.5WIC and SNAP play a fundamental role in improving health outcomes, especially when large inequities already exist.15 For example, WIC participation reduces health inequities among Black and Hispanic mothers/infants (higher birth weights, shorter infant hospitalizations, lower rates of neonatal intensive care unit stays, and lowers rates of infant mortality).3,16 Access to SNAP has been shown to reduce racial and ethnic inequities in food insecurity among low-income households, particularly among Black families.17 Both programs act synergistically to improve food insecurity from childhood to adulthood, highlighting the positive impact of both programs across the life course.2 However, the inequities in WIC and SNAP participation suggest a need for improved access, particularly for underrepresented groups. Addressing barriers, such as administrative burdens, may further enhance WIC and SNAP’s role in reducing health inequities.Several well-known barriers at the individual, organizational, and structural levels are associated with lower coverage rates for eligible but not enrolled populations (Table 1). Visits to the health care system represent unique opportunities to connect patients with WIC and SNAP, especially considering the frequency of well visits in the first 3 years of life. However, health care systems are often physically and electronically isolated from community agencies and social services despite shared goals and patient populations. National organizations, such as the American Academy of Pediatrics and the Food Research & Action Center (FRAC) have recommended that health care systems integrate WIC and SNAP referral processes to help bridge these gaps.24,25 However, connecting patients to these programs from the health care system is not yet a standard of care because of barriers such as difficulty communicating with program staff via telephone, fax, or through reliance on the family; lack of time during busy clinical visits; lack of standardized and universal screening workflows; perceived stigma by patients when being asked these questions in clinical settings; data-sharing/privacy concerns; and lack of compatibility among electronic record systems.18,26–28Over the last decade, there has been growing recognition of the widespread negative effects of food insecurity on health outcomes and health equity,29,30 which has led national health care organizations to recommend that health systems routinely screen for and assist patients with food insecurity and other unmet social needs. For example, the 2023 Joint Commission incorporated food insecurity and other unmet social needs into its accreditation standards, requiring accredited organizations to screen for food insecurity and address health disparities and provide information about community resources and support services.31As part of a comprehensive strategy to screen for and address food insecurity in clinical settings, clinicians can incorporate referrals to WIC and SNAP in clinical settings in addition to referring to other community-based resources. The first step is improving clinician and staff education about the programs, which should begin in professional school and continue throughout training. Clinicians already in practice should be given continuing education credit for educating themselves through a variety of resources.32,33 The next step is effectively disseminating knowledge to clinic staff and patients about the importance of these programs, which could help overcome the knowledge barrier. As clinicians are a trusted source of information for parents, recommendations to explore these programs could influence behaviors.34 Signage about the programs could be posted in examination rooms and hospital settings, normalizing conversations and decreasing stigma. Many states have online referrals for WIC, so a quick response code to this application could be included in the signage.For health care systems wanting to provide direct connections to WIC and SNAP, clinicians can develop relationships with county and state agencies for WIC and SNAP to establish potential partnerships and referral processes. To save time, these referral processes can be incorporated into established workflows for positive food insecurity screenings as referrals for all eligible, nonparticipating families who consent, the latter of which may address barriers caused by bias and stigma.35 Health care systems can also establish data privacy and sharing agreements with agencies, which may improve communication between health care settings and WIC and SNAP, increase program participation, ensure retention, and reduce the number of in-person visits to agencies.18 Both the National WIC Association and FRAC have developed toolkits for clinicians to provide direct connections to WIC from health care settings, which could also be adapted to SNAP.36,27 For example, innovative interventions that have overcome several participation barriers have included electronic health record referrals, targeted outreach to eligible families via a community health worker using an informatics approach, and embedding WIC and SNAP staff in clinical settings to facilitate enrollment. Early evidence has demonstrated the effectiveness of incorporating WIC and SNAP referrals in clinical settings, leading to successful enrollment and information sharing, with clinically embedded program staff, referrals through the electronic health record, and Health Information Exchange–based systems (HIEs) showing promise.38–41 The latter, HIEs, offer access to referrals and standardized medical data without requiring individual connections with different health care systems, a promising practice to addressing multiple barriers.41 Given that WIC and SNAP are important federal nutrition programs that help address food insecurity and promote health equity for infants and children, we recommend clinicians take these steps to incorporate connections to these programs in clinical settings.The policy landscape of WIC and SNAP continues to evolve. The COVID-19 pandemic resulted in program flexibilities through the Families First Coronavirus Response Act in March 2020 that included suspension of certain program requirements (eg, in-person visits, work mandates) that collectively addressed barriers to access and improved participation.42 While some of these changes have lapsed, benefit increases for both WIC and SNAP and remote benefits issuance for WIC are still in place nationwide postpandemic, although remote benefits expire in September 2026.42 Advocacy for the continuation of these waivers is critical. Upcoming budget cuts will significantly decrease funding for SNAP and will indirectly affect WIC because individuals will no longer be adjunctively eligible for WIC—a process that allows families to be automatically enrolled in WIC when they meet income requirements for SNAP.43 An estimated 1 in 4 SNAP participants, including more than 4 million children, live in households that would lose some or all of their food assistance.44 Clinicians can advocate for policies that restore SNAP funding cuts, eliminate administrative and benefit cost-shifts to states, remove new work requirements, restore eligibility to lawfully present noncitizens, and improve data-sharing across agencies to simplify enrollment and recertification processes across public benefit programs. Potential advocacy efforts include writing opinion-editorials to share patient-facing experiences, directly communicating with legislators, collaborating with advocacy organizations such as FRAC, and testifying before local, state, or federal legislators.WIC and SNAP are proven, evidence-based programs that substantially improve child and family health, yet many eligible families remain unconnected. Pediatric clinicians and health care systems have an opportunity and responsibility to close these coverage gaps by incorporating education, screening, and referrals into routine care and by partnering with community and public agencies. As policy changes threaten access to these programs, clinician advocacy is essential to protect and strengthen federal nutrition supports for infants, children, and families.