Is WIC as good as they say? - Special Supplemental Nutrition Program for Women, Infants and Children

Public Interest, Wntr, 1999 by Douglas J. Besharov, Peter Germanis

WIC WORKS, perhaps better than any other government program in existence," Agriculture Secretary Dan Glickman recently declared. Former Health and Human Services Secretary Louis Sullivan agreed: "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. Officially known as the "Special Supplemental Nutrition Program for Women, Infants, and Children," WIC is a several billion dollar program, serving millions of women and children. The program's popularity stems from the widespread belief that research studies have proven that WIC "works." But, although some studies suggest real dietary and health improvements, the great benefits cited above apply only to WIC's prenatal program (only a small part of the total program). Even here the evidence suggests much more modest effects than WIC's boosters claim.

Some will argue that this exaggeration is harmless enough and is for a good cause: $5 billion a year in additional food and counseling services for low-income children and pregnant and breastfeeding or postpartum women. But overstating WIC's effectiveness prevents an honest appraisal of the program and stands in the way of redesigning the program to increase its impact on those who most need its combination of food packages and counseling.

Anatomy of a program

WIC was established 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 argued that nutritional deficiencies among low-income women and children threatened their health and led to higher medical costs. WIC seeks to improve the diets (and, thus, the health) of low-income pregnant, breastfeeding, or postpartum women, as well as their infants and children (up to age five).

Benefits. WIC is a three-part program: (1) vouchers to purchase specific high-nutrition foods to supplement diets, (2) nutritional and health counseling, and (3) referrals to healthcare and social-service providers.

WIC's food "packages" are meant to supplement the recipients' diet, not to meet their entire food or dietary needs. High in protein, calcium, iron, and vitamins A and C, they are designed to provide the nutrients often lacking in the diets of the populations targeted by WIC. Packages typically include iron-fortified infant cereal and formula, juice, milk, cheese, eggs, peanut butter, and beans. Many WIC agencies tailor food packages to meet the nutritional deficiencies of individual WIC clients. For example, if it is known that a WIC participant has high cholesterol, the standard food package may be modified accordingly.

In 1996, the average WIC food package was worth about $45 per month, costing the government only $31 because of manufacturers' rebates on infant formula. This is across all WIC recipients, however. The total value of the two WIC food packages provided to a postpartum mother and her newborn can exceed $100 a month.

Local WIC agencies must spend at least one-sixth of their administrative funds on nutrition education. And WIC recipients must be offered at least two nutrition education sessions each time they are certified. These may be either one-on-one counseling sessions or group classes, designed to teach about the importance of good nutrition and its relationship to good health. Participants are also instructed on how to deal with their own particular nutritional risks and those of their children. Pregnant women are encouraged to breastfeed, for example, unless it's not medically advisable. (In general, these sessions last only about 15 minutes and are voluntary.)

WIC also provides referrals for preventive health care and social services. For example, WIC counselors might send pregnant women to prenatal-care or smoking-education classes, as well as drug- and alcohol-addiction and family-planning services. However, referrals may be a relatively less important aspect of the program because many WIC recipients are already participating in other programs (and may even have been referred from them).

Eligibility. Under federal rules, eligibility for WIC is based on low income and "nutritional risk." Income eligibility is set at family incomes up to 185 percent of the poverty income guidelines ($29,693 for a family of four in 1998). (Recipients of welfare, food stamps, and Medicaid automatically meet the program's income criteria.) Nutritional risk is a broad concept including medical conditions like anemia and low weight; a mother's age, history of pregnancy complications, or poor pregnancy outcomes; and inadequate diets.

The process of determining nutritional risk is inexact, if not permissive. According to the Institute of Medicine's Committee on Scientific Evaluation of WIC Nutrition Risk Criteria, some states use "generous" cut-off points and "loosely defined risk criteria." According to the report, there are "serious gaps on the evidence" for some of the risk criteria. And the tools to measure them are unreliable. Moreover, some of the criteria seem to be quite loosely applied, being dependent on the judgment of "street-level bureaucrats" who can qualify someone who is marginally at risk or not at risk at all, as Peter Rossi points out in Feeding the Poor: Assessing Federal Food Aid. Although the extent of these problems is not known, the Department of Agriculture (USDA), which administers WIC, has revised its guidelines to improve the process for evaluating nutritional risk.