Association of State Supplemental Nutrition Assistance Program Eligibility Policies With Adult Mental Health and Suicidality

Abstract

Importance: Food insecurity is associated with an increased likelihood of poor mental health and suicidality. The Supplemental Nutrition Assistance Program (SNAP) is the largest program addressing food insecurity in the US; under broad-based categorical eligibility (BBCE), states have the option to expand SNAP eligibility to a greater number of households by eliminating the asset test or increasing the income limit for eligibility.

Objectives: To examine the association of state elimination of the asset test and increases in the income limit for SNAP eligibility with rates of mental health and suicidality outcomes among adults.

Design, setting, and participants: This ecological cross-sectional study used 2014 to 2017 data on US adults from the National Vital Statistics System and 2015 to 2019 data on US adults from the National Survey on Drug Use and Health (NSDUH) State-Level Small Area Estimates. Analyses were conducted between September and November 2022.

Exposures: State elimination of the asset test only and state adoption of both SNAP eligibility policies (ie, state elimination of the asset test and increases in the income limit) for 2014 to 2017 from the SNAP Policy Database.

Main outcomes and measures: Number of adults with a past-year major depressive disorder, mental illness, serious mental illness, or suicidal ideation and number of adults who died by suicide.

Results: Analyses included 407 391 adult NSDUH participants and 173 085 adults who died by suicide. State elimination of the asset test only was associated with decreased rates of past-year major depressive episodes (rate ratio [RR], 0.92; 95% CI, 0.87-0.98) and mental illness (RR, 0.91; 95% CI, 0.87-0.97) among adults. State adoption of both SNAP eligibility policies (ie, state elimination of the asset test and increases in the income limit) was associated with decreased rates of past-year major depressive episodes (RR, 0.92; 95% CI, 0.86-0.99), mental illness (RR, 0.92; 95% CI, 0.87-0.98), serious mental illness (RR, 0.91; 95% CI, 0.84-0.99), and suicidal ideation (RR, 0.89; 95% CI, 0.82-0.96). Results suggested a decreased rate of suicide death (RR, 0.93; 95% CI, 0.84-1.02) in states with both policies compared with states with neither policy, although this result was not statistically significant.

Conclusions and relevance: State adoption of policies that expand SNAP eligibility may contribute to decreased rates of multiple mental health and suicidality outcomes at the population level.

Figure 1.. State Adoption of Supplemental Nutrition Assistance Program (SNAP) Eligibility Policies, 2014-2017

Switched policy categories indicates states that changed from neither policy to adoption of 1 or both policies between 2014 and 2017, for example (eTable 1 in Supplement 1). State-years with an increased income limit only were excluded from primary analyses due to the small number (9 state-years [4.4%]).

Figure 2.. Associations of State Supplemental Nutrition Assistance Program Eligibility Policies With Mental Health Outcomes and Suicidality Among Adults^a

Comparison group is state-years that did not have the asset test eliminated or the income limit increased for Supplemental Nutrition Assistance Program eligibility (n = 195 state-years). ^aAdjusted for a linear time trend and state minimum wage, refundable Earned Income Tax Credit, maximum Temporary Assistance for Needy Families benefit for a family of 3, Medicaid expansion, recreational marijuana legalization, percent population unemployed, and median household income.