Little is known about the effectiveness of access approaches  due to a lack of reported research. Studies Show Financial Incentives and Nutrition Education Can Positively Affect the Consumption of Targeted Foods, but Little Is Known about Efforts to Improve Access

Several nutrition promotion studies have demonstrated positive effects on  the purchase or consumption of targeted foods. All four studies demonstrated short-term  positive effects on the purchases of targeted foods, consumption, or  weight loss. The review compared the results of studies that used similar outcome  measures and found that most studies reported that the approaches had  statistically significant effects on consumption, as shown in figure 4. Factors to Consider Include the Selection of Targeted Foods, Incentive Amount, Participant Education, and Monitoring and Evaluation

There are several factors that must be taken into consideration in  designing a program that provides financial incentives for the purchase of  targeted foods in the FSP. Selection of Foods to Promote Could Be Controversial and Challenging

Selecting the foods an incentive program is designed to promote could be  controversial. Amount of the Incentive Will Affect Participant Response and Program Costs

Although financial incentives could take many forms, the amount would  need to be large enough to motivate FSP participants to change their  purchasing patterns by buying more of the targeted foods. Measuring results: Researchers could measure changes in participants’  food purchases, consumption, or health outcomes to determine the effects  of a financial incentive program. FNS officials suggested that a  study could compare FSP participants’ purchases with federal dietary  guideline recommendations before and after an incentive program was  piloted. Financial Incentives Could Be Implemented Electronically or Using Paper Methods, but Each Option Has Potential Implications for Ease of Implementation, Program Integrity, and Cost

An incentive program—delivered in the form of an additional FSP  allotment tied to the purchase of certain foods targeted for promotion— could be implemented through electronic or paper methods, and each of  the options would have implications for ease of implementation, program  integrity, and cost. Electronic options include providing additional FSP  benefits to the EBT cards currently used by FSP participants or to a  separate card on the basis of the amount participants spend on the foods  targeted for promotion. Electronic Delivery of Incentives to Existing EBT Cards May Be Easy for Participants to Use, but Would Require Several Changes to the EBT System

Incentives provided electronically by using existing EBT cards would build  on the current checkout technology and process, may not require as much  time to check out as using a separate card, and could minimize the risk of  fraud. Calculating and applying the incentive: To apply incentives to  participants’ EBT accounts, EBT contractors would need to develop  software for calculating and applying the incentives and to modify their  software to include a new transaction type that tracks the amount spent  on the targeted foods. Paper Delivery of Incentives Would Not Require Changes to the EBT System, but Could Increase State Administrative Costs and Fraud Risk

Delivering incentives using paper methods, such as vouchers or coupons,  may be easier and less costly for some retailers to pilot because these  methods would not require changes to the EBT system, according to a few  of the retailers we interviewed. In general, the officials agreed  with our findings and concluding observations. Appendix I: Objectives, Scope, and Methodology

The objectives of this report were to identify (1) what is known about the  effectiveness of financial incentives and other approaches intended to  increase purchases of targeted foods that could contribute to a healthy  diet; (2) the key factors to consider in designing a program that provides  Food Stamp Program (FSP) participants with financial incentives to  purchase certain foods; and (3) options available to the U.S. Department  of Agriculture’s (USDA) Food and Nutrition Service (FNS) for  implementing financial incentives, and the advantages and challenges  involved in implementing such options. To further explore targeted food incentive options and implementation  issues, we convened a panel of 17 experts representing USDA, states,  retailers, EBT contractors, and manufacturers of retailer check out  systems.
Why GAO Did This Study

In fiscal year 2007, the Food Stamp Program provided about $30.4 billion in nutrition assistance benefits to 26.5 million individuals. Benefits are issued through Electronic Benefit Transfer (EBT) cards, similar to debit cards, to purchase eligible foods at authorized retail stores. The diets of many low-income individuals, like the U.S. population overall, do not meet federal dietary guidelines. One potential strategy for increasing the purchases of targeted foods that contribute to a healthy diet is to incorporate into the program financial incentives for purchasing these foods. GAO was asked to identify (1) what is known about the effectiveness of financial incentives and other approaches intended to increase the purchase of targeted foods, (2) the key factors to consider in designing a financial incentive program, and (3) options available to the U.S. Department of Agriculture's Food and Nutrition Service (FNS) for implementing financial incentives. GAO interviewed agency and state officials, retailers and associations, private EBT contractors, and other stakeholders; convened a panel of 17 experts; and conducted a literature review. In commenting on this report, FNS generally agreed with GAO's findings and concluding observations.

What GAO Found

A variety of approaches, including financial incentives and nutrition education, can increase the consumption of targeted foods, but little is known about the effectiveness of efforts to increase access to targeted foods. A few studies examining the effectiveness of financial incentives have demonstrated short-term positive effects on purchases, consumption, or weight loss. A study that reviewed 92 nutrition education studies found that most studies reported significant positive effects on consumption. Because of a lack of reported research, little is known about the effectiveness of approaches intended to improve access to targeted foods. Factors to consider in designing a program that delivers financial incentives through an additional food stamp allotment tied to the purchase of targeted foods include the following: (1) Selection of foods: Selecting which foods to promote could be a controversial and challenging part of designing an incentive program. (2) Incentive amount: The amount of the incentive will affect participant response and program costs. (3) Informing participants: Participants must be informed of the availability of incentives to take full advantage of a new incentive program. (4) Program monitoring and evaluation: Monitoring and evaluating the incentive program is critical to maintaining program integrity and determining the effects of the program. An incentive program could be implemented through either electronic or paper methods, and the different options would have implications for ease of implementation, program integrity, and cost. Electronic options include adding food benefits to the EBT cards currently used or to a separate card on the basis of the amount that participants spend on targeted foods. Providing incentives using existing EBT cards would build on the current checkout technology and process, and could require less time to complete transactions compared with using a separate card. However, delivering financial incentives to participants' EBT accounts on the basis of their purchases of certain foods would require several changes to the EBT system, such as modifications to retailer and EBT contractor software to separately track the amount spent on the targeted food items. Administering incentives using a separate card, such as an additional EBT card, may be more costly and complicated to implement. Alternatively, providing participants with paper vouchers for the purchase of targeted foods would not require changes to the EBT system, but could be more burdensome to use, increase fraud risk, and increase state administrative costs. With the new authority provided as part of the Food, Conservation, and Energy Act of 2008, FNS will have the opportunity to develop and administer a pilot incentive program and to determine both its effects on participant purchasing and consumption patterns and the costs associated with such a program.