Hunger, health care, and the ACA


By Todd Post

Congress appears set to repeal the Affordable Care Act (ACA), also known as Obamacare. This is a bitter pill to swallow for all of us because of the law’s contribution to solutions to the national hunger crisis. It’s not hyperbole at all to suggest that the Affordable Care Act could be the most important anti-hunger program ever enacted in the United States. More time would tell us, but its time seems to be running out.  

One of the most important features of the ACA is its focus on the social determinants of health. It is widely understood among those who work in the health field—from doctors and other providers, to researchers and insurers—that the leading causes of poor health are social conditions.

Hunger and food insecurity are among these serious health conditions rooted in social conditions. Lack of affordable, healthy food is all too common among people in poor health. People who suffer chronic health problems, as a large percentage of people living with poverty do, often face the no-win “choice” between food and health care.

Poor health drives many people into poverty in the first place, while people who are poor are at greater risk of being unhealthy. Poverty and poor health reinforce each other in this vicious circle. This means that without the guarantee of affordable health insurance, anyone in the United States is at risk of both poverty and poor health. 

Tens of millions of Americans got health insurance through the ACA, many of whom were previously uninsured. For too many people, health insurance was just too expensive, and a significant number had pre-existing conditions, often excluded from health insurance coverage.

In fact, more than 52 million American adults under age 65 have pre-existing conditions that could allow the private insurance market to deny them coverage. In every state, at least 20 percent of working-age adults has a potentially uninsurable pre-existing condition. The percentages are higher in states with high poverty rates. In Arkansas, Alabama, Kentucky, Mississippi, and West Virginia, for example, one-third or more of non-elderly adults have pre-existing conditions.

Many Americans know little about the Affordable Care Act. They may know that millions of people are now covered, that insurance companies can’t deny coverage for pre-existing conditions, and that everyone is required to have health insurance. This “individual mandate” is the most controversial part of the ACA. It is also the key to the whole thing, because we can reduce the costs for everyone by spreading the risks. The larger the pool of insured people, the lower the costs for an individual. Unfortunately, ideologies often interfere with this common sense reasoning.

Often, people don’t realize that specific health insurance plans are part of Obamacare because the plans are offered (and named) by their states. But federal ACA funding, distributed to states that agree to make more people eligible for Medicaid, is the reason that the states can offer the insurance. The Medicaid provisions of the ACA are particularly important for people living with poverty and at risk of hunger.

The Nourishing Effect: Ending Hunger, Improving Health, Reducing Inequality, which is Bread for the World Institute’s 2016 Hunger Report, explained how the ACA provides sound reasons and concrete opportunities to change the way policymakers think and talk about U.S. hunger and what must be done to solve it. Our country has higher rates of hunger and food insecurity than any other rich country. People sometimes forget that we all pay for this, whether or not we face hunger or food insecurity ourselves. We pay taxes to meet the extra healthcare costs of people who receive Medicare or Medicaid, and we also bear the cost of hunger and food insecurity in the form of higher premiums in the private insurance market.

The 2016 Hunger Report included new research on the healthcare costs of U.S. hunger and food insecurity. John Cook of the Boston Medical Center and Children’s HealthWatch and Anna Paula Poblacion of the Universidade Federal de São Paulo in Brazil surveyed the medical literature on the additional costs of treating people who are suffering from hunger and food insecurity. They estimated that hunger and food insecurity increased U.S. healthcare expenditures by at least $160 billion in 2014.

The $160 billion is a conservative estimate, since a number of potential or likely costs are not part of the total because there is not yet sufficient rigorous evidence to support including them. It seems only logical that being forced to “choose” between food or medicine, as mentioned earlier, would add to healthcare costs—for one thing, the cost of disease complications suffered by those not taking all their medication as prescribed. But these costs have largely not been determined and/or calculated in the medical literature.

Americans pay more for health care than any other rich country in the world, not only in absolute dollars but as a share of our national income. So controlling health care costs is one of the biggest, if not the biggest, economic challenges of our time. We could save a great deal of money if health care providers could use food as medicine, prescribing fruits and vegetables or assistance in buying healthy food when they know that a patient’s risk of relapsing is due more to an empty refrigerator than anything else. The ACA has been making these kinds of reforms possible.

Repeal of the Affordable Care Act is fast approaching, but we don’t have any real sense of what its replacement will look like, or whether it will preserve the focus on hunger, food insecurity, and other social determinants of health. Eliminating this important step forward in the fight against hunger would be such poor judgment.

Todd Post is senior researcher, writer, and editor at Bread for the World Institute.

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