Financial strain among U.S. adults with cardiovascular conditions following reductions in food assistance benefits: a quasi-experimental policy analysis

Background Food insecurity is a major driver of poor cardiovascular outcomes, due to poor diet quality and increased financial strain forcing individuals to make difficult tradeoffs between food and health care.1 While food assistance programs directly mitigate these effects, several programs worldwide have undergone significant funding cuts.2 In the United States, recent legislation3 cut $186 billion from the Supplemental Nutrition Assistance Program (SNAP) and will reduce or eliminate benefits for 4 million people monthly. However, the effect of food assistance reductions on financial strain among adults with cardiovascular conditions – a medically vulnerable group due to their high health care needs – remains unknown. Purpose Using the March 2023 expiration of COVID-19-related SNAP supplemental benefits (emergency allotments [EAs]) as a natural experiment, we assessed differential changes in health care-related financial strain among low-income U.S. adults with cardiovascular conditions before and after SNAP EAs expired. Methods This cross-sectional study used 2022-2024 National Health Interview Survey data. The intervention group included SNAP-enrolled adults age ≥ 18 years with hypertension, hyperlipidemia, diabetes, coronary heart disease, myocardial infarction, or stroke residing in 9 U.S. states where EAs expired March 2023. The control group was adults in the same states who met income eligibility criteria but were not enrolled in SNAP. Using a difference-in-differences design, changes in self-reported health care-related financial strain in the intervention versus control groups were compared before (March 2022-Feburary 2023) and after (April 2023-June 2024) SNAP EAs expired. To do this, we fit multivariable linear regression models adjusted for age, sex, race/ethnicity, education, and month/year fixed effects. We also assessed differential changes among working-age adults (age 18-64), who may be less insulated from high health care costs in the absence of Medicare coverage. Pre-parallel trends were met by visual inspection and formal statistical testing. Results Among 1,508 NHIS participants (weighted N=12,310,409 ± SE 547,992; mean age 48.1 years, 55.8% female), we found a 9.0 percentage point (95% CI 0.2-17.8 PP, p=0.045) increase in health care-related financial strain among SNAP-enrolled adults versus controls after EAs expired (Figure). Our sensitivity analysis of working-age adults demonstrated similar findings (+14.4 percentage points, 95% CI 2.0-26.8 PP; p=0.020). Conclusion After reductions in food assistance benefits in the United States, low-income adults with cardiovascular conditions experienced an ~10 percentage point increase in health care-related financial strain relative to controls. Our findings raise concern that ongoing cuts to food assistance programs – both in the U.S. and globally – may exacerbate financial hardship and worsen downstream cardiovascular outcomes.