During the health care summit last week, Sen. Tom Coburn (R-Okla.) suggested that America needs to restructure some of the systemic culture that leads to poor health in the first place, and not just invest in costly treatment of people once they're sick. In particular, he mentioned a pair of intriguing culprits.
"We actually create more diabetes through the food stamp program and the school lunch program than probably any other thing," he said, precisely because we're not incentivizing people to eat well.
Coburn's literal claim is hard to fact-check; there are no statistics (nor would it be possible to obtain them) comparing the complex contributing factors of diabetes in America. But the senator - a doctor by background - makes a solid point, if not an oversimplified one.
Low-income shoppers on a constrained budget, the very group these programs target, often make the rational decision in the supermarket to buy the most energy-dense foods limited dollars can afford. And, in the American supermarket, it just so happens that you get more calories per dollar from soft drinks than fruit juice, from refined grains than whole grains, from frozen french fries than fresh broccoli.
"In other words, the foods, beverages, snacks or diets said to promote obesity were, in every case, inexpensive," Adam Drewnowski, director of the Center for Obesity Research at the University of Washington, wrote in a 2007 article in Epidemiologic Reviews. "What epidemiologic research seems to have shown, fairly consistently, is that obesity is most closely associated with habitual consumption of low-cost foods."
The food stamp and school lunch programs aren't exactly instructing people to eat unhealthy foods. But the reality is that unhealthy food is what limited funds can buy in America.
"To my mind, saying to a low-income person, 'Why don't you choose to eat a healthy, nutritious diet?' is not much different from saying 'Why don't you choose to live on Park Avenue?'" Drewnowski wrote in an e-mail. "Choice has little to do with it."
The fundamental dynamic that makes this true has nothing to do with how federal food aid programs are structured. The problem is more deeply rooted in U.S. farm policy in which subsidies to vast monocultures of corn and soybean commodity crops have created an array of processed ingredients like high-fructose corn syrup that are cheaper than raw vegetables. (It also turns out that processed foods typically have higher profit margins than fresh foods do, feeding a web of interests vested in the status quo.)
This much — that a box of sugared cereal costs less than a pound of apples — is unlikely to change anytime soon. But as Coburn suggested, perhaps we could do more to enable people in the food stamp and school lunch programs to buy healthier foods. The programs don't currently encourage people to pick potato chips, but they also don't encourage them to take home raw potatoes.
Both programs were born in the 1930s. The problem then was that some people simply weren't getting enough to eat, not that they weren't eating nutritiously enough. Food stamps were more an anti-poverty program than a healthy-eating one. Shifting to a greater consciousness around nutrition is difficult, in part because food stamp advocates are wary of any policy that smells of paternalism — telling poor people what they can and cannot eat.
So if the federal government doesn't want to tell people their food stamps or free lunch won't cover junk food, could it at least create something like the frequent-shopper incentives that get you two bananas for the price of one? Or is that also a step down the road to condescension? Food stamps are now electronically administered with the equivalent of a debit card. It doesn't seem like such a stretch that that card could now be used to communicate to the cash register that the recipient gets certain discounts (subsidized by the government) on healthy foods, just as other shoppers get regular deals.
Another suggestion, at the state level where all food stamp programs are administered, is to open recipients to more options, such as farmers markets, where fresh produce can be cheaper than it is at the supermarket. Several states are also now allowing food stamps to be used at restaurants, although an ambiguous cast of commercial alternatives has stepped forward to participate. They include Subway, but also Dominos and Popeye's.
These are precisely the places where you can get a full, hot meal for well under five bucks, and it's hard to fault a hungry person who takes that deal. But this is probably not what Tom Coburn had in mind, underscoring another dilemma: If health care reform is tied up in the American diet, and the American diet is tied up in industrial-scale food policy, how are we supposed to change all of it?