Dimensions: 6.25'' x 9.25'' 180 pages AEI Press  (Washington) Publication Date: January 2001 Paperback ISBN: 0844741493 Price: $ 17.00 Add to Cart   Hardcover ISBN: 0844741485 Price: $ 35.00 Add to Cart   Examination Copies

November 2001
Rethinking WIC: An Evaluation of the Women, Infants, and Children Program
By Douglas J. Besharov and Peter Germanis

To prevent the physical or medical problems among low-income women and their children caused by nutritional deficiencies, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides healthy foods, together with nutrition education, counseling, and referral services, to needy pregnant and postpartum women and to their children under age five.

In this book, Douglas J. Besharov and Peter Germanis review research evaluating WIC's effectiveness and conclude that the program's overall benefits are modest at best. However, instead of recommending that WIC be abandoned or cut, Besharov and Germanis call for a sustained effort to make it more effective. The volume contains a series of recommended policy and programmatic changes and concludes with comments from five leading experts on the program.

Besharov is the Joseph J. and Violet Jacobs Scholar in Social Welfare Studies at AEI. His recent books include America's Disconnected Youth: Toward a Preventive Strategy (1999) and Enhancing Early Childhood Programs: Burdens and Opportunities (1996). Germanis is a research associate at AEI and the assistant director of the University of Maryland's Welfare Reform Academy. This summary is adapted from the book's introduction.

"WIC works, perhaps better than any other government program in existence," declared Agriculture Secretary Dan Glickman during his tenure. Former Health and Human Services secretary Louis Sullivan has made a similar claim: "The WIC Program results in significant Medicaid savings that far outweigh the program's costs by a ratio of 3 to 1 ... That is clearly an overwhelming return on a small national investment." Such statements testify to the extraordinary bipartisan support enjoyed by WIC, the Special Supple-mental Nutrition Program for Women, Infants, and Children. Unfortunately, the research evidence amassed by Besharov and Germanis does not support such claims.

Congress established WIC in 1972 as a two-year pilot program partially in response to the 1969 White House Conference on Food, Nutrition, and Health. The conference report concluded that nutritional deficiencies among low-income women and children threatened their health and led to higher medical costs. To avoid preventable physical or medical conditions, WIC seeks to improve the diets and, therefore, the health of low-income pregnant, breastfeeding, and post-partum women as well as their infants and children up to age five.

Among the conditions WIC is intended to ameliorate are prematurity and low birthweight among pregnant women and compromised development among infants and children.

Currently, WIC is a $5 billion per year program that serves about 7.3 million women and children. Although WIC is a program of the U.S. Department of Agriculture, most of its grantees are state health departments. Those state agencies, in turn, fund WIC services though local health-related agencies such as health departments, hospitals, public health clinics, and community health centers.

WIC's popularity stems from the widespread belief that research studies have proved that WIC "works." Although some studies suggest real improvements in the diets and health of recipients, the extensive benefits cited by Glickman and Sullivan relate only to research conducted on WIC's prenatal program (which involves only about 11 percent of program participants). Even there the evidence suggests that WIC's benefits are modest at best.

WIC's Impact

Rethinking WIC describes in detail the major WIC evaluations and the reasons why they show little about the program's effectiveness. On the basis of not just this body of research, but also of what is known about the impact of similar programs, Besharov and Germanis draw the following conclusions:

• Studies of WIC's impact are almost entirely nonexperimental; in other words, they are based on statistical comparisons made between those who received WIC benefits and those who did not. As a result, many are subject to severe methodological problems, such as selection and simultaneity bias. Moreover, most studies are of limited applicability to assessing the current program because they are based on the program as it existed more than a decade ago and thus do not reflect the composition of the caseload today.
• WIC probably makes at least a small improvement in the diets and behaviors of some pregnant women, especially the most disadvantaged; that improvement, in turn, may improve the birth outcomes for some infants.
• WIC probably increases the nutritional intake of some infants, especially those who would not have been breastfed, but the health consequences of the increases are not clear. Moreover, WIC may reduce breastfeeding, which can have negative health consequences.
• In all, WIC probably makes little significant difference in the diets of one- to four-year-old children, but it may affect some subgroups more noticeably, especially those comprising children whose intake of nutrients one might otherwise consider inadequate.
• WIC has expanded beyond the truly disadvantaged, even though new participants are unlikely to need or benefit from the services it provides.
• WIC is largely irrelevant to the most serious nutritional problem facing disadvantaged Americans: overweight.
• WIC does not result in the major cost savings that its advocates claim, and it may not even pass a basic benefit-cost test.
• Some observers argue that exaggerating WIC's effectiveness is for a good cause--it helps support the allocation of $5 billion a year in additional food, nutrition education, and counseling services for low-income infants and children, pregnant women, and breast- feeding or postpartum mothers. But overstating WIC's effectiveness undermines support for the research and programmatic flexibility needed to increase the program's beneficial impact. For example, over the past decade, additions to WIC's funding have had the effect of expanding the program into the lower middle class when the increases probably could have been much more effectively used to improve or intensify services for generally needier families (a point to which we return later). WIC's rigid spending rules, for example, effectively prevent local programs from spending more than about thirty minutes for nutrition education every six months with clients and preclude enriching food packages with such items as iron supplements.

Recommendations for Reform

The need to improve the WIC program is crucial. Even if WIC were as effective as its advocates claim, the program must do much more to improve diet-related health outcomes for low-income Americans. In fact, from 1986 to 1998, the incidence of low birthweight increased by 12 percent. Surely, we should strive for a WIC program that is as effective as possible. Moreover, Congress developed WIC almost thirty years ago, when hunger was the major nutrition-related problem facing disadvantaged Americans. Since then, overweight has superseded hunger as our most serious nutrition-related health problem. We must now consider updating WIC's mission by adding a specific focus on preventing overweight.

As the foregoing summary suggests, existing WIC research, at least when read in the most favorable light, provides some (and perhaps substantial) support for the proposition that WIC has significant social and policy effects on particular subgroups of participants. The research has not clearly established the makeup or identity of those subgroups, but they seem to comprise the neediest families-the poorest of the poor.

In the future, policymakers should pay much greater attention to such differential effects, especially because they might suggest more focused service strategies. As Peter H. Rossi noted in Feeding the Poor: Assessing Federal Food Aid (AEI Press, 1998), that lack of focus on subgroups is one of the shortcomings of most current research: "Currently available evaluation studies place too much emphasis on central tendencies-means and medians-and do not give enough attention to measures of the distributions of responses and differentials among subgroups."

To increase WIC's positive impacts, Besharov and Germanis propose a series of possible reforms, each to be thoroughly evaluated:

• Services should be targeted to the more needful families, the group that seems to benefit most from WIC.
• State and local WIC agencies should have more flexibility to expand the basic food package and to intensify nutritional counseling.
• WIC should seek to prevent overweight and obesity through education, counseling, and food preparation classes.
• WIC should cover children over the age of four, because problems like overweight worsen as children get older.
• Counseling should be more directive, because many nutritional problems are caused by unhealthy behaviors rather than by lack of food.
• WIC should try different service providers, such as health care providers, that can offer a full range of health and nutrition services.
• All the foregoing programmatic reforms should be rigorously evaluated, preferably through randomized experiments.

Reforms along those lines have a good chance of making WIC more effective. Even if they do not, that does not mean that such expansions of the program are not socially worthwhile, so long as they are more carefully targeted than current services. Making even a small number of children, especially poor children, healthier-without harming others and without exorbitant spending-would be an ethical benefit not captured in purely economic benefit-cost calculations. As Jane Huntington and Frederick A. Connell wrote in the New England Journal of Medicine:

We should consider whether cost savings is the appropriate criterion by which to judge prenatal care programs. It is tempting to assume that in order for these programs to be valuable, they really should save more than they cost. Yet when we require prenatal care, and other preventive health care, to pay for itself, we may be inadvertently denying valuable benefits to society. It may be better to ask not "How much does this save?" but, rather, "How much is this worth?"

Hence, this volume does not argue that WIC's weaknesses justify abandoning or even cutting the program. On the contrary, policymakers should undertake a sustained effort to make the program more effective. Congress should begin that effort by debating the role and impact of WIC and by granting greater flexibility to state and local WIC agencies to open the program to innovation and experimentation. In addition, policymakers should carefully evaluate any changes. Furthermore, the federal government should conduct a series of randomized demonstrations to determine more definitively the impact of each of WIC's program components-with particular attention paid to key subgroups. If evaluations prove those ideas sound, the result could be a major shift in who gets served and how. But that consideration should not prevent needed reform. Chapters 2 and 3 of this volume describe the WIC program. Chapters 4, 5, and 6 review and assess the research on the program's impact. Chapter 7 recommends state-based experimentation along the lines of the policy reforms listed above. Chapter 8 calls for a series of randomized experiments to evaluate the program and any changes made to it, and chapter 9 briefly presents the conclusions reached by Besharov and Germanis.

Part 2 of this volume includes comments on the authors' study by five leading experts of WIC program research. Michael J. Brien of the University of Virginia and Christopher A. Swann of the State University of New York at Stony Brook describe their efforts to address the selection-bias problem and the implications of their findings for program targeting and design. Nancy R. Burstein of Abt Associates explains the methodological problems encountered in dealing with selection bias and then describes an incremental approach to testing the efficacy of WIC with randomized experiments. Barbara L. Devaney of Mathematica Policy Research offers a defense of the existing research by arguing that Besharov and Germanis have overstated the research problems in assessing WIC's effectiveness. She does, however, offer support for some of the policy options they present. Robert Greenstein of the Center on Budget and Policy Priorities also argues that Besharov and Germanis have overstated the research problems affecting WIC and concludes that they are overly pessimistic about the program's impact. Like Devaney, he believes that some of the policy ideas deserve "serious consideration" but considers others to be "troubling" and likely to reduce WIC's effectiveness.

Instead of attempting to rebut the disagreements that exist between themselves and the commentators in a separate response, the authors reflect the basis of their conclusions in the main text.