Currently in the United States, childhood injuries are the leading cause of mortality and morbidity, resulting in an estimated 9.2 million emergency department visits and $17 billion annually in medical costs [2]. For preschoolers, it is also the leading cause of disability [10]. Poverty is a risk factor for experiencing childhood injuries and injuries are more prevalent among low-income families [1, 27, 4]. Besides demographic risk factors, other known correlates of childhood injury tend to focus on diminished parenting practices [10, 19, 23,24,25, 32] and increased child behavior problems [8], which are also correlated with maternal stress and income. For children under 15, the unintentional injury mortality rate was the highest among those less than 1 year of age, followed by children 1 to 4 years of age [2]. While the overall unintentional mortality injury rate for the US is 15.0 per 100,000, for the state of Missouri, this rate is 21.2 per 100,000. Previous research suggests that food insecurity is likely to be a catalyst for many of the specific mechanisms that increase the likelihood of childhood injury [3, 33]. This study explores the extent to which food insecurity, or the inconsistent access to food through socially acceptable ways, is associated with temporal patterns in ER visits for childhood injuries among children less than 5 years of age in the state of Missouri.
Our study population is comprised of children age 0–5 who participated in both Medicaid and the Supplemental Nutrition Assistance Program (SNAP), a federal nutritional program that provides food assistance in the form of vouchers with an average household value of $255 to purchase food products, seeds, and plants that produce food for consumption to low-income individuals. SNAP is the largest food assistance program administered by the US Department of Agriculture, serving 18 million children (one in four children) in 2016 [7]. Sixty-nine percent of children in households receiving SNAP are school aged (age 5 to 17) and 55% of all households with children earned any income [30]. According to one estimate, over the entire childhood period, nearly half of all children will reside in a household that receives food stamps at some point [3, 26].
Households are income eligible for SNAP if they have a gross monthly income below 130% of the federal poverty line or, by state option, through participation in another low-income assistance program. Furthermore, children in Missouri are eligible for public health insurance if they reside in households with household incomes below 148% of the federal poverty line [21], meaning that all children in households who are income-eligible for SNAP benefits are also income-eligible for Medicaid.
The federal government provides states with flexibility in deciding how they disburse benefits. While many states choose to disburse SNAP benefits within the first 9 days of the calendar month, at the time of this study Missouri was the only state in the country to issue SNAP benefits between the 1st and 22nd day of the month, with the specific calendar day assignment based on a combination of the case head’s first letter of the last name and their birth month. For example, on the 1st everyone born in January with last name A-K receives benefits, on the 2nd everyone born in January with last name L-Z receive benefits, and on the 3rd everyone born in February with last name A–K receives benefits [31]. Since the date of SNAP benefit payment varies across households according to rules that are outside the control of individual decisions or outcomes, these data are ideal for examining the causal impact of benefit payment timing. As we observe in Figures 1 and 2 in Appendix, the percentage of SNAP recipients receiving SNAP disbursement, as well as the average amount of benefits receiving is very similar through the calendar month (from day 1 through 22). This demonstrates the exogenous variation in the SNAP disbursement data used to identify our models.
The introduction of SNAP is associated with positive improvements in child outcomes [18]. However, there is also evidence that because SNAP benefits are often exhausted well before the next issuance date, household food consumption may be inconsistent as households deplete their resources ( [5, 6, 14, 29]. National estimates suggest that 60% of SNAP households use all of their benefits in the week following benefit disbursement and 91% of households use all of their benefits in the first 3 weeks following benefit disbursement.
In this paper, we examine how SNAP participation affects patterns in ER visits for childhood injuries. We hypothesize that among households that receive SNAP, depletion of benefits over the month might increase childhood injuries near the end of the month as both child and parental behaviors deteriorate under the strain of food insecurity. Several theoretical arguments support this hypothesis. First, prior research has documented that there are monthly patterns to the SNAP benefit exhaustion [6, 15], and that households reduce food intake at the end of the benefit month because of financial hardship [34]. Further research finds that food spending decreases toward the end of the calendar month among SNAP households that receive benefits early in the calendar month but not among SNAP households that receive benefits later in the calendar month [9]. Thus, previous research has linked the distribution of SNAP benefits to within month cycles in food insecurity.
Secondly, previous research has linked the timing of household SNAP benefit receipt to children’s test scores and negative behaviors [11,12,13]. Given the focus in the childhood injury literature on diminished parenting such as not coping with parenthood well, low rule enforcement, lack of supervision, low levels of every day routines, and maternal fatigue [10, 19, 23,24,25, 32] as well as increased child behavior problems [8], we examine the relationship between timing of SNAP benefits and Medicaid claims for ER visits for childhood injuries using data from Missouri. By combining state administrative data from two programs, this study makes an important contribution to our understanding of the social and environmental predictors of flare-ups of childhood injuries while also exploring the consequences of specific implementation choices related to food and nutrition policies, such as the date of SNAP benefit disbursement.