Food and Housing Insecurity, Stress, and Health Care Use After Medicaid Expanded Services Program

Abstract

Importance: Massachusetts implemented a Flexible Services program (FSP) under a Medicaid Section 1115 waiver to address food and housing insecurity for accountable care organization (ACO) beneficiaries. Little is known about the social, behavioral, and clinical outcomes associated with Medicaid social needs interventions.

Objective: To compare 1-year changes in food and housing insecurity, diet, stress, and acute health care use between individuals who participated in the Massachusetts FSP and those who did not.

Design, setting, and participants: This prospective cohort study enrolled adult Medicaid beneficiaries from 5 community health centers in 1 eastern Massachusetts ACO from December 2019 through December 2020. Participants who were enrolled in FSP were compared with propensity score-weighted FSP-eligible study participants who were not enrolled in FSP (hereafter non-FSP participants). All FSP participants completed surveys and dietary recalls at enrollment and then annually for 3 years. In-depth interviews were conducted with 27 FSP participants. All data analyses were conducted from August 2024 to April 2025.

Exposure: Enrollment in FSP.

Main outcomes and measures: Primary outcomes were 1-year changes in food and housing insecurity, stress, dietary quality, and acute health care use. Secondary outcomes were changes in depression and anxiety symptoms. Annual surveys measured food insecurity (10-item US Department of Agriculture Food Security Scale Module; score range: 0-10, with ≥3 indicating food insecurity), housing insecurity (questions regarding current housing, moving ≥2 times in past year, and worrying about losing housing), and stress (the 10-item Perceived Stress Scale [PSS]; score range: 0-40, with ≥14 indicating moderate to severe stress). Diet quality was measured with the Healthy Eating Index-2020 (HEI-2020; score range: 0-100, with higher scores indicating healthier diet quality). Acute health care use included annual emergency department (ED) visits and acute hospitalizations.

Results: There were 153 FSP participant episodes (representing 153 study participants; mean [SD] age, 43.6 [10.8] years; 129 females [84.3%]) and 1495 non-FSP participant episodes (representing 610 unique study participants; mean (SD) age 43.2 (11.2) years; 464 females [76.1%]) in the sample. Before FSP enrollment, 111 (72.5%) had food insecurity, 68 (44.4%) had housing insecurity, and 55 (35.9%) had both. There were no differences between the FSP and non-FSP groups in changes in proportion of individuals with food insecurity (difference in change, 4.96%; 95% CI, -3.13% to 13.05%) or housing insecurity (difference in change, 2.75%; 95% CI: -5.39% to 10.88%). There were no differences between groups in HEI-2020 scores, PSS scores, or acute health care use. Participant interviews reflected a range of experiences associated with FSP, from favorable changes in social needs and health to persistent challenges related to cost of food and limited housing availability.

Conclusions and relevance: This study of adult Medicaid beneficiaries found that FSP was not associated with short-term favorable changes in food or housing insecurity, diet, stress, or acute health care use. In interviews, FSP participants highlighted both the benefits and challenges of addressing social needs through such health system interventions.

Figure.. Study Flow Diagram of Participants Included in the Flexible Services Program (FSP) and Non-FSP Groups in the Analytic Sample

FSP-eligible indicates a participant in the Medicaid accountable care organization, with food or housing insecurity, and with a diagnosis that would fulfill criteria for program enrollment.