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We see the value of the federal government’s Supplemental Nutrition Assistance Program (SNAP) almost every day. It allows some of our patients to meet a basic human need: to eat. In our medical practices, we are intimately aware of the inextricable link between poor diet and health: arteries hardened, nerves numbed, and cancers caused. This is why we are concerned about farm bills working their way through Congress that threaten the SNAP program.

Last month, the House of Representatives passed the Agriculture and Nutrition Act of 2018 (H.R. 2, also known as the Farm Bill), which could have immensely harmful consequences for the health of millions of Americans. It includes a proposed reform of SNAP that creates an arduous and draconian work requirement that would compel roughly 7 million recipients to prove they work at least 20 hours per week or are pursuing job training. If they don’t, they risk losing SNAP benefits.

The documentation to demonstrate that won’t be a simple process for many.


SNAP beneficiaries are already required to provide excessive documentation to get food assistance, which sets the bar for receiving services unacceptably high and puts people at risk of food insecurity. The House bill would further increase this burden by requiring monthly proof of meeting the work requirement. The application process and ongoing work reporting may be perceived as being so onerous that they discourage people from applying who could and should qualify for SNAP.

We are concerned about the fate of our patients — mothers who work the equivalent of multiple jobs in the informal sector as caregivers, the elderly, people with disabilities or illness — who may not meet the requirements related to work, disability, child rearing, or caregiving for the disabled. An estimated 2 million people stand to lose food assistance or face reductions in what they receive. This will unequivocally take a toll on the nation’s health through hunger, stress, fatigue, increased infections, and increased reliance on cheap but less nutritious foods that lead to diabetes and cardiovascular disease.


The House bill penalizes SNAP beneficiaries who have an unexcused lapse in meeting the work requirement by taking away their benefits for a year; subsequent infractions result in the loss of benefits for three years. This includes people whose health conditions limit their ability to work but who do not meet SNAP’s disability exemption. We are concerned about our patients with chronic, debilitating disease such as lupus or Crohn’s disease that cause them to miss work in the midst of an inflammatory flare, perhaps driven by poor access to nutrition in the first place.

During a time when the economy is at near full employment, ineffective work requirements do nothing to aid those who participate in the program or improve our collective economic wellbeing. We favor food policies that help both health and the economy. The USDA economic impact model suggests that every dollar spent on SNAP is an economic multiplier, yielding roughly $1.80 in economic activity. And since a large share of SNAP recipients live in rural regions, the subsidy often supports small business such as local food retailers and grocers, hurting the very constituents and political base that’s driving this reform.

The Senate has just passed its version of the farm bill. It continues to support food assistance programs at current funding levels without including the work requirement. The two bills must now go to a joint House and Senate congressional conference, where they will emerge as some amalgamation of the two.

A new survey of registered voters by the Johns Hopkins Bloomberg School of Public Health’s Center for a Livable Future found that nearly two-thirds oppose cuts to SNAP. We hope that senators and representatives will listen to their constituents and not end or cut benefits for 2 million people by increasing requirements and bureaucracy.

These changes and cuts would hurt patients and families all across the country. As physicians, we believe that food is medicine and that the proposed changes to SNAP would strain our ability to provide health care to those who need it most, as we are pulled to address both food insecurity and its needless complications during our clinical encounters. At a time when diet-related diseases are the leading cause of death in the U.S., we should ensure that food becomes more accessible and more secure rather than the opposite.

Andrew Goldstein, M.D., is an internal medicine primary care physician and Akash Goel, M.D., is a gastroenterologist. Both are health policy advocates and work in New York City.

  • As a health professional and consume seeing what is covered by SNAP, there should be restrictions on the types of foods covered which are increasing the obesity in the country and worsening the medical outcome of those covered. What I see individuals purchasing for their children with the snap cards is sickening for a nutritionist. Sodas, juices, potato chips, and fries chicken should not be items covered if we want to really help these people. The farmers markets that work with cooperative extensions offer so much better options but are often unknown. Perhaps changing what is covered should be changed.

    • This is exactly the problem here, “Health Professionals” who choose to blame the people effected. Professionals who are not bright enough to look at how their own, unfounded and informed judgements, are making this worse. They choose to avoid looking at the bigger picture, because so many “Health Professionals” have found fame and profit, in misinforming the public.
      We never see any so called “Health Professionals” weigh in on how these products are marketed, even when children are targeted. Not many of these so called Health Professionals, looked into how poverty , stress and marginalization were effecting “those peoples” peoples health.
      None of these judgmental and uninformed health professionals protested against certain types stores, replacing grocery stores in low income neighborhoods.
      We never see these health professionals discuss, how the marketing, of cheap processed food, combined with the lack of availability of anything fresh, led up to this. None of these Experts spoke up when Dollar Stores, chose to provide more profitable and shelf stable garbage foods, as grocery stores closed. They did to speak up when the big box stores, and fast food joints proliferated.
      Here in Post Fact America is is just easier and more popular, to let people starve or do without, rather than look at systemic inequality, low wages, food deserts, and industry marketing.

    • Mavis Johnston… I am a dietitian who has worked at the front line of SNAP for Cornell Cooperative Extension Farmers Market Prohram who volunteer our time to help educate those about cooking vegetables that they have never heard off and helping them to make unseasoned and no added salt ( part of the requirement of the program) recipes. I see how marketing in New York and limited grocery stores ends up causing bodega stores with limited options. This is why I brought up this suggestion. Do you know how frustrating it is to try to educate someone on the right foods to save their foot from being amputated due to uncontrolled diabetes and being told “well I am comfortable with the food I eat and not willing to change?” So before you raise judgement on “health professionals”, I have worked with those in need. I make less than most professionals in the health field and realize the cost just as much as my patients. I don’t make that much from my work. I can tell you that when those in the hospital that are poor and I offer education on what best to pick is often refused. I was just hoping that reform could help in that area. Excuse me for giving an opinion.

    • Ms Olivia!
      That sounds so terribly dismal, “unseasoned” it is food not a punishment. When I was a child, my diabetic grandmother cut her toe on a shampoo bottle. They took her toe, then her foot and then her leg. Today I have acquaintances, who are blind due to diabetes. Now I live in a small town with 2 dollar stores, where the only ‘food” is packaged processed garbage. You practically trip over displays of soda suitcases. A nearby town considered a “Soda Tax” thinking it might reduce soda consumption, the grocery, beverages and restaurant industry spent millions to defeat it. They were going to spend the tax money on Early Childhood Education. Our state has been cutting educational funding for 2 decades, and recently, 2014, had a Lawsuit to determine if not funding education was a violation of our state Constitution. A Judge decided it was. They had particularly cut funding to Minority students. It was very likely racially motivated, while at the same time our local news peddled Charter Schools.

      20 years ago, one of our Governors decided that they would sell soda in the schools, and allow Coca Cola to provide “educational” TV programming in the classrooms. They claimed it would “save money,” educate the kids and the schools would get income from the Coca Coal Corporation. Other than crazy people like myself everyone else was on board. Of course most of those making the decisions could afford to send their kids to good schools.
      A while back during a visit to the dollar store, I watched a young mother put the wrong brand of child cereal in her basket. She chose the store brand it was a coupe of bucks cheaper. Her 3 year old son pitched a fit, threw a tantrum that could be heard through the entire store. He was very likely exposed to advertising already. These stores use up a lot of shelf space for a reason, with sugary cereal. Children are being indoctrinated with marketing and advertising almost from birth, yet no one seems very concerned. The so called Experts are still blaming the people who are effected.
      Your attitude is not that unusual, it is fairly pervasive. I spoke with a 300 pound young woman, I had given her a ride, but the set belt would not close around her. She had a long list of health problems including Diabetes, Hormones, and her joints giving out, from her weight. I asked her if her Doctor has ever discussed her Fast Food intake. She lived in subsidized housing, which was conveniently located right next door to a MC Donald’s. It never occurred to her that eating every meal there was not healthy. It most certainly never occurred to her Physician either.

      My theory is that the Judgmentalism, contempt and disgust, displayed by “helpers,” is extremely counter productive. These attitudes are very pervasive, and are not improving anything. Our state started a “Wellness” campaign, and i realized that there are 2 levels to “Wellness.” There is what the people who can afford it consider Wellness, and what there really is for the lower income, minority, you know, “Those people.” My theory is that this is almost Genocidal.
      Think of all of the people who are invested in Fast Food, big box stores, convenience stores, they profit from the misfortune of these poor sick people. Communities don’t speak up anymore when another of these monopolistic behemoths moves into a neighborhood. These big chain Pharmacies too. Across America, the same few retailers, every few miles. In lower income areas, a plethora of dollar stores, fast food and chain pharmacies, that sell alcohol too. Local Police Departments don’t even count the number of crimes, or incidents, at these big retailers, it could be inconvenient for these corporations. In Fact there is virtually no criticism of these mega corporations at all.
      Recently a young man who worked at a fast Food restaurant, replacing the immigrants, mostly women with children, wiling to tolerate the abuse, stopped his truck, and walked in front of a train. He was 24 years old. No one mentioned the terrible working conditions, or the fact that thanks to artificially low wages, there was zero hope for this young man. In the newspaper, they stated that he needed “Mental Health.” That has 2 levels too, one the side they show in movies, that people with good incomes and insurance have access to, and the other a faith based organization, community Mental Health. He would have had a 5 minute interview, if lucky, and then he would have been prescribed a random assortment of anti psychotics and anti depressants. None of this would have made his job more tolerable. These companies have micro managed every bit of labor out of their workers, and demean people at every opportunity. No one ever says anything critical, it is not allowed.
      We are all exposed to a toxic brew of continual advertising, your “opinion” is the popular one. We are not allowed to discuss marketing, corporate greed, and profiteering off of the most vulnerable, instead we should blame the people who are dying because of it. Perhaps you should educate yourself, read the packaging on some of this garbage food. Even thought they make a big thing over labeling, looks at how these corporations, use it to mislead. The biggest most profitable retailers use tricks that would have been illegal 25 years ago. The “Meat” is now a combination of salts, sugar, and liquid, “solution.” 20% is not meat, it is liquid added for weight. I have explained this to diabetics on many occasions. The same with “Fat Free” anything with that label is probably really bad for us.
      I doubt any experts or “Nutritionists” have ever explained how these label are designed to deceive. I found that people respond to being ripped off, more than the added sugars and salts. People are paying 7.99 a pound for salt water, which is a rip off.
      See attitudes like your serve a purpose, they deliberately blame the victim which is much safer than looking at the root causes. Turn on you local TV News, you will be inundated with advertising. Walk down the aisles in your grocery store, and look at how everything is arranged in order to confuse, mislead, and propel overwhelmed people to buy more garbage.
      The Experts are most certainly not discussing any of this, most of the “Research” is funded by these industries. Look at Oprah, selling diets and pharma products on her network. No one says hey wait a minute, the are too brainwashed. Did you know that Physicians recommend “Exercise” because the sugar and soft drink industries told them to. the idea was they could ignore the consumption of soda all day, and offset those calories with exercise. They did not want any Physicians telling their patients to cut out soft drinks, or fast food, that could cut into profits.

      We are in Post Fact America, blaming the victim is safer and a lot more profitable, that exposing ourselves to Facts. Shaming people has been proven not to work, but that does not mean they wont keep trying it. It is no wonder there are people on those scooters at Wal Mart, loading up on greasy deli food. Thanks to these misguided “Helpers” we have toddlers that weigh 100 pounds, because people are trained to show ‘Love” by feeding them sugar, the only thing they can afford!
      Nutritionists seem to have some huge blind spots, when they were “educated” the corporations designed the curriculum. Here you are obsessing over salt, when the packaging on most food is designed to hide the amount of added salt. Salt is about the only thing left that does not have a corporate gag order tied to it. That is why dieticians are so obsessed with it.

  • I am, admittedly, poorly educated about the specifics of governmental dietary supplementation programs. But, I am well-educated about the need to work in order to gain material benefits. “There ain’t no such thing as a free lunch”-the cornerstone of capitalism–can be taken entirely literally in this case. I presently work an average of 60 hours per week, and I generate loads of complicated paperwork (EHR notes) every day–all as a requirement to get paid so that I can eat. If the authors are so concerned about the beneficiaries of SNAP working 20 hours per week, are you triply concerned about me working 60 hours per week? If not, why not?

    • A Straw Man Argument fresh from mass media. One reason why not, is that many of the recipients are children. They are too short to drive, reach a cash register or lift heavy items. We learned back in the good old days, that putting children to work, led to lack of education stunted growth and a lot of injuries and fatalities.

      If you hate your job so much Doctor, perhaps you should change the Laws so that Doctors can organize and Strike. It might be helpful to investigate why our broken healthcare system has Physicians doing so much paperwork in the first place. Taking you misspelled anger out on the most vulnerable is not going to help, even though your well heeled friends, industry lobbyists, and targeted marketing tell you so. It really should be a crime that a Physician is spending so much time on burdensome paperwork, instead of seeing patients or having a life. I really wonder what it is going to take for people to get out of their information silos, and face reality. You should blame the corrupt insurance lobby, bought and paid for politicians and policy makers, and the corporation that you work for.
      People are pushing for Medicare For All, or Universal Healthcare, for a reason. The system is to cumbersome and corrupt to be sustainable anymore.

    • Mavis: I think you assumed that I am unhappy–I am not! I love my job and am grateful to get to do it. I only asked a question–do the authors think that my 60 hour work week with cumbersome paperwork is bad for my health and would they advocate paying me my salary if I did not do it?

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