Cost-Benefit Analysis of HealthyMatch:

A Rhode Island Nutrition Incentive Program

Prepared for Reece Lyerly & the Rhode Island Public
Health Institute

Prepared by Emily Frank, Erik Gartland, Amanda Hejna,

Kassandra Martinchek, Lillian Schultze & Hannah Stephens

January 2018
Table of Contents

LIST OF TABLES AND FIGURES iv

ACRONYMS v

ACKNOWLEDGEMENTS vi

EXECUTIVE SUMMARY vii

INTRODUCTION 1

POLICY OPTIONS 2
CURRENT POLICY: FOOD ON THE MOVE 2
ALTERNATIVE: HEALTHYMATCH PILOT PROGRAM 3

PROGRAM COSTS 3
UPFRONT COSTS 4
ONGOING COSTS 4

PROGRAM BENEFITS 6
AVOIDED COSTS OF CORONARY HEART DISEASE (CHD) 8
AVOIDED COSTS OF STROKE 9
AVOIDED COSTS OF DIABETES 10
AVOIDED COSTS OF CANCER 11
AVOIDED COSTS OF DEPRESSION 12
INCOME TRANSFER 12
DIRECT CONSUMER SURPLUS 13
NON-MONETIZED BENEFITS 13

RESULTS 15
SENSITIVITY ANALYSIS 16

LIMITATIONS 17

RECOMMENDATIONS 20

ENDNOTES 21
REFERENCES 23

APPENDIX A: DEMOGRAPHICS OF SNAP HOUSEHOLDS IN RHODE ISLAND, 2016 28

i
APPENDIX B: COSTS OF THE SNAP PROGRAM IN RHODE ISLAND 31

APPENDIX C: FOOD ON THE MOVE SITE LOCATIONS 32

APPENDIX D : PROPOSAL FOR THE DEVELOPMENT OF STATE NUTRITION INCENTIVE PLAN 33

APPENDIX E: OVERVIEW OF THE HEALTHY INCENTIVES PILOT 37

APPENDIX F: COST ESTIMATES BASED ON THE HEALTHY INCENTIVES PILOT 41

APPENDIX G: PARTICIPANT RECRUITMENT COSTS 45

APPENDIX H: COSTS AND BENEFITS OF HEALTHYMATCH BY YEAR 47

APPENDIX I: PREVALENCE AND INCIDENCE OF DISEASES 49

APPENDIX J: FRUIT AND VEGETABLE SERVING SIZES 54

APPENDIX K: EFFECT OF HEALTHYMATCH CONSUMPTION ON RELATIVE RISK 58

APPENDIX L: DIRECT AND INDIRECT COSTS OF CORONARY HEART DISEASE 60

APPENDIX M: RELATIVE RISK OF CORONARY HEART DISEASE DUE TO FRUIT AND

VEGETABLE CONSUMPTION 62

APPENDIX N: DIRECT AND INDIRECT COSTS OF STROKE 64

APPENDIX O: RELATIVE RISK OF STROKE DUE TO FRUIT AND VEGETABLE CONSUMPTION 67

APPENDIX P: DIRECT AND INDIRECT COSTS OF DIABETES 69

APPENDIX Q: RELATIVE RISK OF DIABETES DUE TO FRUIT AND VEGETABLE CONSUMPTION 73

APPENDIX R: DIRECT AND INDIRECT COSTS OF CANCER 75

APPENDIX S: RELATIVE RISK OF CANCER DUE TO FRUIT AND VEGETABLE CONSUMPTION 78

APPENDIX T: DIRECT AND INDIRECT COSTS OF DEPRESSION 80

APPENDIX U: RELATIVE RISK OF DEPRESSION DUE TO FRUIT AND VEGETABLE CONSUMPTION 82

APPENDIX V: INCOME TRANSFER FROM HEALTHYMATCH 84

APPENDIX W: CONSUMER SURPLUS FROM HEALTHYMATCH 85

ii
APPENDIX X: REDUCTION IN TRANSPORTATION COSTS 86

APPENDIX Y: EXTERNALITIES ASSOCIATED WITH POVERTY 88

APPENDIX Z: FOOD INSECURITY AND EDUCATIONAL OUTCOMES IN CHILDREN AND

ADOLESCENTS 89

APPENDIX AA: SENSITIVITY ANALYSIS 91

APPENDIX AB: STANDARD ERRORS AND UNCERTAINTY ESTIMATIONS 93

APPENDIX AC: RELATIVE RISK OF DISEASES BY OBESITY STATUS 97

APPENDIX AD: MONTE CARLO STATA CODE 99

iii
LIST OF TABLES AND FIGURES

TABLE 1: BENEFIT VARIABLE DESCRIPTIONS 8

TABLE 2: SUMMARY OF BENEFITS 15

TABLE 3: SUMMARY OF COSTS 16

FIGURE 1: NET BENEFITS OF HEALTHYMATCH OVER 10 YEARS, 3.5% DISCOUNT RATE 17

iv
ACRONYMS
ACS American Cancer Society
ADA American Diabetes Association
AHA American Heart Association
ARIC Atherosclerosis Risk in Communities
BMI Body mass index
BRFSS Behavioral Risk Factor Surveillance System
CBO Community based organization
CDC Centers for Disease Control and Prevention
CHD Coronary heart disease
CI Confidence interval
CPI Consumer Price Index
CVD Cardiovascular disease
DTA Department of Transitional Assistance (Massachusetts)
EBT Electronic Benefits Transfer
FAQ Frequently asked question
FOTM Food on the Move
FY Fiscal year
HEALTH Rhode Island Department of Health
HIP Healthy Incentives Pilot
IECR Integrated Electronic Cash Register
MDD Major depressive disorder
MEPS Medical Expenditure Panel Survey
METB Marginal excess tax burden
NHANES National Health and Nutrition Examination Survey
NHIS National Health Institute Survey
NHLBI National Heart, Lung, and Blood Institute
POS Point of sale
PVNB Present value of net benefits
RI Rhode Island
RIPHI Rhode Island Public Health Institute
RR Relative risk
SBP School Breakfast Program
SD Standard deviation
SE Standard error
SNAP Supplemental Nutrition Assistance Program
STD Short-term disability
USDA United States Department of Agriculture

v
ACKNOWLEDGEMENTS
We would like to thank Reece Lyerly, Program Manager of Evaluation, and Eliza Dexter Cohen, Food

Access Coordinator, at the Rhode Island Public Health Institute for providing their experience, knowledge

and guidance in helping us create the following report. We would also like to thank Limestone Analytics

for their collaboration on this project. Additionally, we would like to thank Laura Dionne, Data Manager

at Brown University, for providing us with valuable data for our analysis. Finally, we would like to thank

Professor David Weimer for his guidance and expertise throughout the semester.

vi
EXECUTIVE SUMMARY
We analyzed the costs and benefits of the HealthyMatch pilot program in Rhode Island (RI),

which aims to expand use of a nutrition incentive program to grocery stores and other retail settings. The

HealthyMatch program, proposed by the Rhode Island Public Health Institute (RIPHI), is modeled after

the Healthy Incentives Pilot in Massachusetts. If implemented, it will provide Supplemental Nutrition

Assistance Program (SNAP) recipients with a one-to-one dollar match for fruit and vegetable purchases.

SNAP provides nutrition assistance to low-income individuals through an allotment of funds to spend on

food. Low-income households tend to experience food insecurity, or difficulty accessing enough food or

quality food. While SNAP has been found to reduce food insecurity among participants, SNAP and low-

income households often consume low quality diets, leading to potential adverse health consequences. By

expanding the number of locations at which SNAP recipients can use their benefits to purchase fresh

fruits and vegetables at a discounted rate, RIPHI hopes to improve population health and nutrition, reduce

long-term healthcare costs for participants, and reduce the incidence of food insecurity across the state.

We estimated the total net benefits of the program, based on the benefits we were able to monetize, to be -

$14.87 million over the 10 years following its implementation. That is, excluding non-monetized benefits,

its adoption would induce a net loss to society of $14.87 million.

Implementation of the HealthyMatch pilot would require several upfront expenditures, including

the system design costs, borne by both RIPHI and participating grocery stores, and retailer recruitment

costs. There are also various annual expenditures associated with the program including the nutrition

incentive benefits paid to SNAP beneficiaries, retailer training, participant recruitment, partnerships with

community based organizations, and general administrative costs. The benefits of HealthyMatch result

from subsidies paid for current fruit and vegetable consumption, the direct value of fruit and vegetable

consumption, and avoided costs of the following diseases to SNAP beneficiaries who will participate in

the program: coronary heart disease, stroke, diabetes, cancer, and depression.

The large number of unquantifiable benefits, the inferences we had to make about the RI SNAP

population based on national samples, and our omission of obesity as a health outcome from the model

vii
indicate the need for further data collection and research. With more directly applicable data on the effect

of increased fruit and vegetable consumption on reduced relative risk of disease, as well as monetization

of non-monetized benefits, a future cost-benefit analysis could yield more robust estimates. Specifically,

we recommend data collection on the prevalence and incidence of various chronic diseases in the RI

SNAP population, relative risk of these diseases among SNAP recipients, time costs related to assessing

product eligibility, healthy food preparation, and transportation to grocery retailers, as well as the

association between fruit and vegetable consumption and reports of mental health and well-being. We

would also advise instituting a nutrition education program to promote changes to healthy behavior.

We performed a Monte Carlo simulation to determine the robustness of our results. We

conducted 10,000 trials and determined the distribution of net benefits across these trials. Our Monte

Carlo simulation yielded a mean value of net benefits of -$14.87 million with almost 100 percent of the

trials returning negative net benefits based on the impacts that our team was able to monetize. However,

due to the numerous impacts of the program that could not be monetized, the net benefits of

HealthyMatch are likely much greater than reported.

viii
INTRODUCTION
Food insecurity measures a household’s difficulty in accessing enough food as a result of

constrained resources over a 12-month period. In 2017, 12.4 percent of Rhode Island (RI) households

were food insecure by this measure.1 Three different levels of food security are used to indicate the degree

to which households struggle to provide sufficient food to their members: marginal, low, and very low.

Marginal food security describes households that are anxious about their ability to afford food, but that

experience few changes in food intake; low food security describes households with lowered quality,

variability, or desirability of food intake; and very low food security describes households with lowered

diet quantity in response to limited household resources.2 The Supplemental Nutrition Assistance

Program (SNAP), formerly known as the Food Stamp Program, provides nutrition assistance to income-

eligible individuals through an allotment of funds to spend on food.3

Extensive research has linked food insecurity to an increased risk of chronic disease conditions,

many of which require a healthy diet for ongoing management. These conditions include hypertension,

heart disease, hepatitis, stroke, cancer, asthma, diabetes, arthritis, chronic obstructive pulmonary disease,

and kidney disease.4,5,6 Increasing food security can be an effective mechanism for decreasing chronic

disease incidence and minimizing other population health problems; however, while SNAP has been

shown to reduce food insecurity among its beneficiaries, participating households still have lower diet

quality than income-eligible non-participants.7,8,9 In general, poverty and food insecurity are associated

with lower fruit and vegetable consumption in favor of high-fat, energy-dense diets.10 Due to their high

water content, fruits and vegetables are not energy-dense relative to high-fat foods. As such, individuals

with limited financial resources to allocate to food will select less expensive but more energy-dense foods

to maintain dietary energy. Nutrition incentive programs attempt to address this consumption pattern by

offering financial inducements to promote consumption of fruits and vegetables and improve diet quality

among low-income populations.11

1
 Approximately 171,000 Rhode Islanders– about 16 percent of the state’s total population –

received SNAP benefits per month of fiscal year 2016 (see Appendices A and B).12 In a strategic plan for

RI to promote sustainability, economic growth, and community health, researchers identified nutrition

incentives as a key mechanism for improving food security.13 The Hunger Elimination Task Force, a

coalition of organizations committed to eradicating food insecurity, aims to bolster existing nutrition

initiatives through the creation of the first statewide SNAP nutrition incentive program in the country.14

Because of its small population, RI represents a potentially low-cost testing ground for statewide SNAP

nutrition incentive programs that could be implemented in larger states in the future.

POLICY OPTIONS
Current Policy: Food on the Move
The Rhode Island Public Health Institute (RIPHI) launched Food on the Move (FOTM) in 2015,

in accordance with a program model shown to increase fruit and vegetable consumption among

participants. FOTM’s primary missions are to “make fresh, healthy foods accessible and affordable to

everyone,” and to address the structural challenges that Rhode Islanders face to eating more fruits and

vegetables.15 RIPHI administered a statewide needs assessment to identify barriers, which include high

costs of fruits and vegetables, poor quality fruits and vegetables in low-income neighborhoods,

insufficient time to shop due to hectic lifestyles, and limited access to reliable transportation. FOTM

operates 30 to 40 mobile farmers’ markets each month at 13 sites across the state, offering a dollar-for-

dollar match for SNAP recipients purchasing fruits and vegetables. This essentially provides a 50 percent

discount on any fresh produce purchased with SNAP benefits.

The FOTM markets are designed to target populations that are most vulnerable to food insecurity,

including children and the elderly. As such, RIPHI has focused its efforts on public housing facilities,

neighborhoods with high numbers of families with children, and low-income subsidized senior housing

sites (see Appendix C for FOTM site locations). Though the markets are open to the general public,

approximately 80 percent of FOTM customers live in a household in which one or more members receive

2
SNAP benefits. Since its inception in 2015, FOTM has reached more than 5,000 customers annually,

selling over $270,000 in produce at 775 markets across the state.16

Alternative: HealthyMatch Pilot Program

Current SNAP nutrition incentive programs in RI and other states are offered primarily at farmers

markets, accounting for only 3.6 percent of total SNAP benefits used nationwide. RIPHI has proposed a

pilot program, described below, that would extend the nutrition incentives offered at FOTM markets into

grocery stores and other brick-and-mortar retail settings statewide.17 The proposed pilot, which our team

has unofficially named HealthyMatch, is intended to build on the effectiveness of FOTM and other

nutrition incentive programs by further increasing accessibility to fresh produce for SNAP recipients.

Similar to the current policy, retail locations included in the expansion would effectively provide a 50

percent discount to SNAP recipients for fruit and vegetable purchases. By expanding the locations at

which SNAP recipients can use their benefits to purchase fresh fruits and vegetables, RIPHI hopes to

improve population health and nutrition, decrease long-term health care costs for participants, and reduce

the incidence of food insecurity across the state (see Appendix D for a detailed description of the program

proposal).

Prior to implementing HealthyMatch, RIPHI is conducting a multistage planning and coalition-

building process, including the following action steps:

● Reviewing existing research on nutrition incentive programs nationally and globally

● Identifying barriers to scaling nutrition incentive programs to retail environments
● Convening a coalition of local and national public and private stakeholders to provide input and
advocacy
● Engaging potential funding partners

If successful, HealthyMatch may provide an evidentiary basis to support the implementation of the

program model in other states or nationwide.

PROGRAM COSTS
The cost estimates included in our model were based on the Healthy Incentives Pilot (HIP), a

comparable nutrition incentive program implemented in Massachusetts between 2011 and 2012 (see

3
Appendix E for a detailed description of HIP). Where necessary, we performed adjustments to account for

programmatic and scale differences between HIP and HealthyMatch. We categorized costs into upfront

and ongoing costs, where upfront costs are incurred only in the first year and ongoing costs are incurred

in each year of the model’s ten-year time horizon. An extensive review of the adjustments performed can

be found in Appendix F. Below are brief summaries of each cost category, based on the descriptions

provided in the HIP Final Report.

Upfront Costs
The equation below was used to calculate upfront costs:

System Design: This cost category includes the costs incurred by retailers and RIPHI in facilitating

retailer infrastructure changes. Retailer Integrated Electronic Cash Register (IECR) systems would have

to be modified to accommodate HealthyMatch benefits.

Retailer Recruitment: Grocery retailers throughout RI would be recruited to participate in HealthyMatch.

This cost includes the performance of recruitment tasks and ongoing communication with retailers, as

well as internal expenses incurred by RIPHI staff.

Upfront Opportunity Cost of Raising Public Funds: We included a separate cost category to capture the

opportunity cost to society of raising tax revenue to fund the implementation of the HealthyMatch

program. Upfront opportunity cost was calculated by multiplying a marginal excess tax burden (METB)

of 0.19 by the total government expenditures incurred in Years 0 and 1, including the nutrition incentive,

implementation, and annual recurring costs of the HealthyMatch program.18

Ongoing Costs
The equation below was used to calculate ongoing costs:

4
General Administration: RIPHI staff would provide management and oversight activities for the

HealthyMatch program, including establishing a Memoranda of Understanding, creating contractual

relationships with retailers, hiring additional staff, and facilitating internal operations. Ongoing costs are

incurred annually for personnel, supplies, and overhead necessary to maintain the program each year.

Nutrition Incentives: HealthyMatch provides a dollar-for-dollar match for every purchase of fruits and

vegetables using SNAP benefits made at a participating retailer. Ongoing costs of the incentive are

incurred as SNAP participants make food purchases in each year of our model’s time horizon.

CBO Partnerships: RIPHI would partner with various community based organizations (CBOs) in an effort

to encourage sustained involvement in and support for HealthyMatch. Costs are incurred annually as

additional outreach is performed in the years following the program’s implementation.

Training: RIPHI staff would develop training materials and conduct training sessions to teach

participating retailers and consumers about HealthyMatch. Training costs are incurred annually as a result

of employee turnover in the grocery retail industry in RI.

Participant Recruitment: In order to engage consumers in the HealthyMatch program, RIPHI staff would

develop recruiting materials to be translated, printed, and mailed to participating households. Annual

costs are incurred as additional supplies, such as postage, are needed (see Appendix G for more

information on the costs of participant recruitment).

Ongoing Opportunity Cost of Raising Public Funds: Ongoing opportunity cost was calculated by

multiplying a METB of 0.19 by the total government expenditures incurred in each year, including the

nutrition incentive, implementation, and annual recurring costs of the HealthyMatch program.

5
PROGRAM BENEFITS
Our analysis considers benefits of HealthyMatch to be avoided costs associated with chronic

diseases, the income transfer associated with the subsidy, and the direct consumer surplus associated with

increased fruit and vegetable consumption. Detailed explanations of each benefit category are below (see

Table H.1 in Appendix H for more information).

We monetized benefits of avoided costs of the following diseases to SNAP beneficiaries who will

participate in the HealthyMatch program: coronary heart disease (CHD), stroke, diabetes, cancer, and

depression. In order to avoid double counting benefits, we excluded any avoided direct or indirect costs of

obesity. We acknowledge that increasing fruit and vegetable consumption has a positive effect on weight

management and the prevention of obesity; however, including obesity-related costs would likely

overstate the benefits of this program.19 As the aforementioned diseases often occur as comorbid

conditions of obesity, we assume that a reduction in risk of obesity would likely lead to a reduction in risk

of these chronic conditions and vice versa. Direct costs refer to annual disease-related medical

expenditures, including but not limited to hospital stays, physician visits, and medication. Indirect costs

are defined as annual lost productivity due to absenteeism, short and long-term disability, and reduced

labor force participation. We limit these benefits to include reductions in morbidity, or the condition of

having a disease or symptoms of a disease. For the purposes of our analysis, we excluded avoided costs

associated with premature mortality. All benefits are reported in 2018 dollars.

We used the same methodology to calculate the avoided costs attributable to each disease. First,

we determined the number of people whose risk of contracting the disease would decrease as a result of

HealthyMatch. To do this, we first subtracted the prevalence of the disease among food insecure

individuals, which is reported as a proportion, from one. This allowed us to determine the proportion of

the population that does not currently have the disease. The unaffected fraction of the population was then

multiplied by the RI SNAP population. Next, we multiplied this number by the predicted proportion of

the RI SNAP population that will participate in the program, which we estimated to be 0.66 based on

take-up rates of the HIP initiative. This number was then multiplied by the incidence of the disease, or the

6
probability of being diagnosed with said condition in any given year (see Appendix I for a detailed

explanation of these estimates). This gave us the probability that a RI SNAP beneficiary who does not

already have the disease will develop the disease in a given year. We multiplied this probability by the

expected decrease in relative risk (RR) of the disease as a result of the anticipated increase in fruit and

vegetable consumption, which gave us in the expected number of annual avoided cases of the disease

among the RI SNAP population.

To determine the expected decrease in RR of each disease, we first calculated the effect size of

the program, or the anticipated increase in fruit and vegetable consumption as a result of HealthyMatch.

We estimated the effect size to be an increase in daily consumption of 0.36 cups, or approximately 49

grams—1.5 times that of the effect size of the HIP program (see Appendix J for a detailed description of

conversions between grams, cups, and serving sizes). Based on these values, we then standardized the

number of grams per serving size utilized in the literature, in order to determine the decrease in RR of

each disease resulting from a daily consumption increase of 0.36 cups of fruit and vegetables. As noted

above, we multiplied this expected decrease in RR of disease by the probability of developing the disease

to obtain the expected reduction in disease development, or annual averted cases (see Appendix K for a

detailed description of these calculations). Finally, to calculate the total estimated benefits associated with

the avoidance of each disease, we multiplied the expected number of annual averted cases by the per

person direct and indirect costs. The equation below was used to calculate benefits associated with

avoided cases of each disease:

7
Table 1
Benefit Variable Descriptions

Variable Name Description

MED Direct medical costs

PROD Indirect productivity costs

Proportion of RI SNAP population that will participate in

POP
HealthyMatch

PR Prevalence

INC Incidence

RR Relative risk

FV Effect size of eating fruits and vegetables, in cups

Benefits associated with avoided cases of diabetes and depression were assumed to begin one year after

HealthyMatch implementation, based on the strong evidence that early intervention through lifestyle

change, particularly a change in diet, can significantly reduce progression from prediabetes to diabetes.20

Further, the length of depressive episodes can vary greatly and there is a significant possibility of

relapse.21 Benefits associated with avoided cases of stroke were delayed to begin three years after

HealthyMatch implementation. While some evidence indicates that diet change rapidly decreases risk of

stroke, other studies indicate that many modifiable stroke factors take years to develop.22,23 Benefits

associated with avoided cases of cancer were lagged to begin five years after Healthy Match

implementation, in year six of the program, as the natural history of the disease can extend over many

years before clinical signs are evident.24 Diet habits over long periods of time also have a significant role

in shaping cancer risk.25 Benefits associated with avoided cases of CHD were also lagged five years for

similar reasons, as diet over an extended time period can affect one’s risk of CHD.26

Avoided Costs of Coronary Heart Disease (CHD)

According to a report from the American Heart Association (AHA), medical expenditures

associated with CHD were projected to be $89 billion in 2015 and indirect costs were projected to be

$16.1 billion. AHA estimated a projected 16,835,804 cases of CHD in 2015 based on data from the 2007-

8
2014 National Health and Nutrition Examination Survey (NHANES). To determine per person medical

and indirect costs, we divided the estimated total costs by the projected number of cases. This method

yielded direct per person costs of $5,720 and $1,034 in indirect costs in 2018 dollars (see Appendix L for

a detailed explanation of these estimates).27

Based on a 2017 report from the U.S. Department of Agriculture (USDA), we assumed a

prevalence of CHD in the food insecure population of 0.046. We estimated the incidence of CHD in this

cohort to be 2.8 cases per 1,000 people using data from the AHA and the U.S. Census Bureau. In a meta-

analysis of cohort studies on the effect of fruit and vegetable consumption on the risk of CHD, the authors

determined that an increase of one serving of fruit and vegetables per day resulted in a pooled RR of CHD

of 0.96 (see Appendix M).28 In accordance with the methodology described above, we used these figures

to calculate an expected number of approximately five avoided cases of CHD in a given year attributable

to HealthyMatch. Multiplying this figure by the total per person cost of CHD, we found an estimate of

approximately $37,000 in annual benefits (see Table H.1 in Appendix H). These benefits were lagged to

begin in year six of the program to account for the natural history of the disease.

Avoided Costs of Stroke

According to the aforementioned report prepared for the AHA, the medical expenditures

associated with stroke were projected to be $36.7 billion in 2015. There were an estimated 7,483,839

cases of stroke in that same year based on data from the 2007-2014 NHANES. We divided the total

medical expenditures by the number of stroke events, resulting in per person direct costs of stroke of

$5,232. We employed a similar method to determine the indirect costs of stroke using the estimates

provided in the AHA report, resulting in a per person cost of $983. Thus, the total annual per person costs

of stroke are estimated to be $6,215 (see Appendix N for a detailed explanation of these estimates).29

Based on a 2017 report from USDA, we assumed a prevalence of stroke in the food insecure

population of 0.0417. We estimated the incidence of stroke in this cohort to be 8.5 cases per 1,000 people

using data from the AHA and the U.S. Census Bureau. In a meta-analysis of cohort studies on the effect

of fruit and vegetable consumption on the risk of stroke, the authors determined that an increase of one

9
serving of fruit and vegetables per day resulted in a pooled RR of stroke of 0.95 (see Appendix O).30 In

accordance with the methodology described above, we used these figures to calculate an expected number

of approximately 21 avoided cases of stroke in a given year attributable to HealthyMatch. Multiplying

this figure by the total per person cost of stroke, we found an estimate of approximately $130,000 in

annual benefits (see Table H.1 in Appendix H). Benefits were lagged to begin in year four of the program

to account for the natural history of the disease.

Avoided Costs of Diabetes

According to a report prepared for the American Diabetes Association (ADA), there were an

estimated 24.7 million people diagnosed with diabetes in 2017.31 These individuals incurred medical

expenditures of approximately $16,750 per year, of which about $9,600 was attributed to diabetes. In

current dollars, this amounts to an annual direct cost estimate of $9,876 per person. To obtain individual

annual productivity costs, we took the ADA’s estimated total annual productivity costs of $90 billion,

subtracted the portion of total productivity costs attributable to mortality, then divided the resulting $70

billion in morbidity-related losses by the number of people diagnosed with diabetes. This resulted in per

person indirect costs of $2,834. Thus, the total annual per person costs of diabetes are $12,710 (see

Appendix P for a detailed explanation of these estimates).

Based on a 2017 report from USDA, we assumed a prevalence of diabetes in the food insecure

population of 0.125. We estimated the incidence of diabetes in this cohort to be 6.7 cases per 1,000 people

using data from the Centers for Disease Control and Prevention (CDC). In a meta-analysis of the effect of

fruit and vegetable intake on diabetes, researchers determined that a daily one-serving increasing in

consumption resulted in a pooled RR of 0.96 (see Appendix Q).32 In accordance with the methodology

described above, we used these figures to calculate an expected number of approximately twelve avoided

cases of diabetes in a given year attributable to HealthyMatch. Multiplying this figure by the total per

person cost of diabetes, we found an estimate of approximately $160,000 in annual benefits (see Table

H.1 in Appendix H). Benefits were lagged to begin in year two of the program to account for the natural

history of the disease.

10
Avoided Costs of Cancer
A meta-analysis conducted by Short, Moran and Punekar (2010) estimated the annual costs of

cancer for newly diagnosed and previously diagnosed individuals. Using two nationally representative

surveys, authors applied classification codes to identify individuals with cancer and scaled the adjusted

weights of the sample to the U.S. population in 2007. Authors found mean annual expenditures for

individuals with newly diagnosed cancer in 2007 were $16,910 ± $3911 and $7992 ± $972 for survivors

who were diagnosed in previous years. Although new diagnoses accounted for only 15 percent of the total

number of cancer survivors, they accounted for 28 percent of total survivor spending.33 For the purposes

of this analysis, only newly diagnosed cases were used. To obtain indirect costs of cancer, Chang et al.

(2004) observed individuals with newly diagnosed cancer and measured the number of days absent from

work and short-term disability (STD) days used. Results found those with cancer were absent five days

per month, a cost of $373 per month ($4,476 per year) and two STD days, a cost of $698 per month

($8,376 per year).34 Thus, the total annual per person costs of cancer are estimated to be $29,762 (see

Appendix R for a detailed explanation of these estimates).

Based on a 2017 report from USDA, we assumed a prevalence of cancer in the food insecure

population of 0.052. We estimated the incidence of cancer in this cohort to be between 0.0046 and 0.0058

using data from the Rhode Island Department of Health (HEALTH) and the American Cancer Society

(ACS).35,36 In a meta-analysis of the effect of fruit and vegetable intake on cancer, the authors found that

an increase of one serving of fruit and vegetables per day resulted in a RR of cancer between 0.805 and

0.975 (see Appendix S).37 In accordance with the methodology described above, we used these figures to

calculate an expected number of approximately 30 avoided cases of cancer in a given year attributable to

HealthyMatch. Multiplying this figure by the total per person cost of cancer, we found an estimate of

approximately $1,140,000 in annual benefits (see Table H.1 in Appendix H). Benefits were lagged to

begin in year six of the program to account for the natural history of the disease.

11
Avoided Costs of Depression
Using national survey and administrative claims data, Greenberg et al (2010) estimated yearly

total and per-person costs of depression in the United States.38 Because depression is often comorbid with

other diseases, they separated costs directly attributable to depression from other medical costs. The

authors found that annual medical costs directly attributable to depression amounted to $6,575.40 per

person in 2018 dollars. Annual lost productivity costs, including both workplace presenteeism (or reduced

productivity in the workplace) and absenteeism, amounted to $1,704.16 per person in 2018 dollars (see

Appendix T for a detailed explanation of these estimates).

According to data from the 2005-2010 NHANES surveys, prevalence of depression in the SNAP

population nationwide is 12.8 percent.39 Depression is measured in the NHANES using a self-reported

Patient Health Questionnaire. We assumed incidence of depression to be 14 diagnoses per 1000 people, or

0.014, based on a study conducted in the United Kingdom.40 A meta-analysis by Saghafian et al. found

that a 100-gram increase in daily fruit and vegetable consumption lowered risk of depression by 3

percentage points, resulting in a RR of depression of 0.97 (see Appendix U).41 In accordance with the

methodology described above, we used these figures to calculate an expected number of approximately

nineteen avoided cases of depression in a given year attributable to HealthyMatch. Multiplying this figure

by the total per person cost of depression, we found an estimate of approximately $160,000 in annual

benefits (see Table H.1 in Appendix H). Benefits were lagged to begin in year two of the program to

account for the natural history of the disease.

Income Transfer
We interpret the effect of HealthyMatch subsidies on the quantity of fruits and vegetables

consumed by a beneficiary prior to participating in the program as effectively providing an increased

level of income for SNAP beneficiaries. Inframarginal consumption, or the proportion of consumption

that would occur regardless of the subsidy, is therefore counted in our model as an income transfer (see

Appendix V for additional information). Average consumption of fruits and vegetables prior to

implementation of HealthyMatch, based on the HIP Report, was assumed to be 0.91 cups per day, and we

12
estimated that HealthyMatch will increase consumption by 0.36 cups per day. Thus, the application of the

subsidy to 0.91 cups is considered the income transfer, which equates to approximately $6,430,000 per

year in benefits.

Direct Consumer Surplus

As stated above, we estimated that the HealthyMatch subsidy will induced program participants

to consume approximately 0.36 additional cups of fruits and vegetables per day. We also assumed that

program participants may not fully account for the health benefits of increased consumption of produce,

and thus estimate a lower level of demand than they would express with full information and income

flexibility. We considered the direct consumer surplus from increased fruit and vegetable consumption to

be a benefit, but one that does not capture the health benefits that we assess in terms of avoided future

disease (for additional information and a graphical representation, see Appendix W).

Non-Monetized Benefits
Beyond the benefits quantified in our model, there are numerous potential non-monetized benefits

of increased fruit and vegetable consumption. These include self-reported well-being and happiness

measures, reduced mental stress, increased overall psychological well-being, slower rates of age-related

cognitive decline, improved cognition, self-reported quality of life, and reduced transportation costs due

to increased affordability of produce in grocery stores nearby (see Appendix X for more information on

reduced transportation costs).42,43,44,45,46,47,48 Furthermore, fruit and vegetable consumption and other

healthy behaviors go hand in hand, suggesting that when individuals choose to consume more fruits and

vegetables, their likelihood of adopting other healthy behaviors may increase. For example, individuals

who consume more fruits and vegetables tend to smoke less, exercise more, and drink less alcohol.49,50,51

Combinations of these healthy behaviors result in lower all-cause morbidity and mortality risk.52 There

may also be a non-monetized inframarginal benefit (that is, a benefit situated below the margin of

increased produce consumption) in the form of the income effect of HealthyMatch. In other words, the

increase in income that HealthyMatch participants would experience as a result of the financial incentive

13
represents a decrease in the negative externalities associated with poverty (see Appendix Y for more

information).

Finally, we were unable to monetize the potential benefits children gain from increased fruit and

vegetable intake, including avoided direct and indirect costs. The literature suggests that there is a strong

association between increased fruit and vegetable intake and academic performance in children and

adolescents.53 Thus, the consumption increase induced by HealthyMatch could result in reduced

absenteeism and improved educational outcomes for this cohort (see Appendix Z for more information).

Children might also accrue a benefit from avoided cases of certain diet-related diseases, although most

diseases that can be prevented through fruit and vegetable consumption do not manifest during childhood.

The risk of CHD and diabetes begins to increase around age 45, the mean age of stroke onset in 2005 was

69.2 years, and the median age of cancer diagnosis in 2015 was 66 years, with advancing age being the

most important cancer risk factor overall.54,55,56,57 Consequently, health care costs associated with these

diseases stemming from inadequate fruit and vegetable consumption are much smaller in children than in

adults.

That said, children who maintain a consistently poor diet may experience certain negative health

outcomes. Mean fruit and vegetable consumption among low-income children who live in a household

whose income is less than 130 percent of the federal poverty line is less than one serving per day.58 This

inadequate consumption increases the risk of various childhood diseases, such as Crohn’s disease.59 In

addition, diseases that typically manifest in adulthood are beginning to appear more often in children,

including Type 2 diabetes.60 Overweight and obesity in children may also predispose them to

comorbidities in adulthood; for example, the high incidence of juvenile overweight and obesity has led to

progressively early signs of cardiovascular risk in children and adolescents.61,62 In sum, although

increased fruit and vegetable consumption induced by HealthyMatch would have a much greater effect on

adult health care costs, it may also carry long-term health benefits for children.63 It is important to note

that the evidence in the literature regarding the sustainability of childhood behaviors into adulthood is

somewhat mixed. 64 Some research suggests that fruit and vegetable consumption in childhood can help

14
children form consistent healthy eating habits that extend into adulthood, while other studies indicate that

fruit and vegetable intake is not yet stabilized at age 13, and that habit changes occur throughout

adolescence and young adulthood. 65,66 Nonetheless, policymakers should consider taking measures that

encourage healthy eating among children, with the hope that they develop and maintain these behaviors

over their life courses.

RESULTS
Our final HealthyMatch cost-benefit model estimated a mean present value of net benefits

(PVNB) of -$8.72 million. Net benefits were calculated by estimating the benefits accrued from avoided

medical and lost productivity costs associated with increases in fruit and vegetable consumption as a

result of participating in HealthyMatch, along with the additional consumer surplus, income transfer, and

inframarginal consumption benefits induced by the program. Table 2 shows the summary of benefits

included in the model, and Table 3 shows a summary of costs included in the model. Annual

HealthyMatch nutrition incentive payments are approximately 1.1 percent of the annual SNAP benefits

paid out in RI (see Appendix B for additional information on SNAP expenditures in RI).

Table 2
Summary of Benefits
For an annual breakdown of benefits, see Appendix H.

Total Benefits

Reduced Diabetes Costs $1,668,000

Reduced CHD Costs $189,000

Reduced Cancer Costs $5,670,000

Reduced Stroke Costs $930,000

Reduced Depression Costs $2,511,000

Direct CS from increased fruit & vegetable consumption $4,330,000

Income from inframarginal consumption $21,893,000

15
Table 3
Summary of Costs
For an annual breakdown of costs, see Appendix H.

ADMINISTRATIVE COSTS

Upfront Costs
Systems design for businesses $190,000
Retailer recruitment $503,000
Upfront retailer training $300,000
Upfront opportunity cost of raising public funds (Year 0) $130,000
Annual Costs
CBO partnerships $62,000
Annual retailer training $160,000
Annual participant recruitment $190,000
General administration $990,000
Opportunity cost of raising government funds (Year 1) $870,000
Opportunity cost of raising government funds (Year 2
$850,000
onward)
NUTRITION INCENTIVE COSTS
Annual nutrition incentives paid out to participants $3,060,000

Sensitivity Analysis
We conducted a Monte Carlo simulation for all cost and benefits included in our PVNB

estimation, in order to account for uncertainty in the estimates used in our model. We assumed a

distribution for each of the parameters. The Monte Carlo simulation randomly drew values from each

parameter distribution to calculate HealthyMatch’s PVNB, repeating this process 10,000 times to produce

a distribution of PVNB. From this, we determined the mean PVNB across all values generated by the

Monte Carlo simulation. The majority of parameters were assumed to be normally distributed, where the

likelihood of a value being drawn at random by the simulation was higher for values closer to the mean. A

smaller number of parameters were determined to be uniformly distributed, meaning all values within a

specified range of possible values were equally likely to occur (see Appendices AA and AB for a more

16
detailed explanation of our sensitivity analysis). The Stata code used in our sensitivity analysis can be

found in Appendix AD.

For our final estimate, we conducted a Monte Carlo analysis using a 3.5 percent discount rate,

0.19 METB, and 10-year time horizon. The resulting distribution of net benefits is shown in Figure 2.

Estimated PVNB range from -$23.94 million to $440,000, with an estimated mean of -$14.87 million

across all trials. In this model, 0.12 percent of trials returned positive net benefits.

Figure 1
Net Benefits of HealthyMatch Over 10 Years, 3.5% Discount Rate

LIMITATIONS
As indicated in our discussion of non-monetized benefits, there were numerous benefits related to

increased fruit and vegetable consumption that we did not include in our model. Consequently, our results

likely underestimate the benefits of the HealthyMatch program. Unquantifiable benefits include: self-

reported well-being and happiness measures, reduced mental stress, increased overall psychological well-

being, improved academic performance, slower rates of age-related cognitive decline, improved

cognition, and reduced transportation costs due to increased affordability of produce in grocery stores

nearby.67,68,69,70,71 These benefits were not monetized because of gaps in the research literature or

17
challenges in modeling within our limited resources. As noted above, we also may have underestimated

the benefits that children gain from the HealthyMatch program. Prevalence and incidence estimates are

derived from population samples that exclude children, meaning we did not consider the benefits accrued

to children who may avoid disease later in life as a result of increased fruit and vegetable consumption.

Further research could develop benefit estimates specific to children.

Several components of our analysis required inferences about the RI SNAP population from

national samples. Because we were unable to find prevalence and incidence estimates specific to the RI

SNAP population, we used U.S. population-wide prevalence and incidence estimates as proxies. Our

estimates of the RR of each disease were drawn from meta-analyses not specific to the RI SNAP

population, which may not be equivalent to that population in terms of demographics, body mass index

(BMI), income, and other factors that affect health. Furthermore, while these meta-analyses provided a

comprehensive synthesis of the literature on the relationship between each chronic disease and fruit and

vegetable consumption, most cited an association rather than a causal link. Consequently, the studies may

have failed to control for potential confounders, biasing our estimates. We also calculated avoided cost

estimates based on national samples that may not have been representative of the population that would

be impacted by HealthyMatch. The RI SNAP population is likely more dependent on Medicare and

Medicaid than the population as a whole and their medical expenses likely differ as such. More detailed

FOTM data could support or modify these estimates in the future. We also chose not to include avoided

costs of reduced productivity due to mortality, or avoided costs in the form of value of statistical lives,

due to the short time horizon of our analysis.

We chose to exclude costs associated with obesity in our estimation of benefits of the

HealthyMatch program. While there is substantial literature illustrating an inverse relationship between

fruit and vegetable consumption and obesity, the chronic diseases included in our model are comorbid

with obesity, and thus may have led to double-counting of benefits had obesity been included in our

model (see Appendix AC for information on the RR of chronic diseases due to obesity status).72 We also

faced several limitations in our estimation of associated with avoided cases of depression. We were

18
unable to take into consideration the fact that depressive episodes typically last a limited period of time

and that individuals can undergo multiple separate episodes of depression. Although the median length of

a depressive episode is approximately 20 weeks, this time frame can vary greatly from one patient to

another and even from one recurrent episode to the next for the same patient.73

Though we received data from RIPHI documenting the purchases made at FOTM markets, a lack

of pre-program implementation data prohibited us from developing estimates of the impact of the one-to-

one dollar match on fruit and vegetable consumption. Thus, we relied on secondary data from HIP to

estimate the expected change in fruit and vegetable consumption. As HIP took place in Massachusetts, it

is not wholly representative of the RI SNAP population. Further, HIP provided a match of 30 cents per

each SNAP dollar spent, and as such, estimates of increased consumption likely underestimate those that

can be expected as a result of HealthyMatch.74 We also used administrative costs reported from HIP and

scaled them to HealthyMatch. While we feel this was the most accurate estimation with information

available, actual costs of implementation may vary slightly. The analysis could be refined once

HealthyMatch administrative costs are more clearly delineated.

We faced several limitations in predicting certain behavioral effects of HealthyMatch. We were

able to estimate the fraction of SNAP households per month that would redeem HealthyMatch incentives,

using the HIP take-up rate of 66 percent (see Appendix F). However, we were not able to obtain estimates

of program drop-off rates to include in our model. Further research is needed to determine whether and

for how long program participants exhibit sustained fruit and vegetable consumption habits.

Finally, we were limited in our ability to estimate the number of retailers who would participate

in HealthyMatch. RIPHI indicated that the first phase of HealthyMatch would include only grocery stores

(for example, convenience stores would not be included) and would begin in Stop and Shop stores.75 We

were unable to obtain a comprehensive list of grocery stores in the state through our communication with

the RI Food Dealers Association. Due to this lack of full information, we estimated the number of grocery

stores that would be first adopters of the HealthyMatch program using a press release from the RI Food

Dealers Association website.76

19
RECOMMENDATIONS
The negative net benefits found in the analysis support a recommendation of further data

collection and research. We acknowledge that a lack of data on the RI SNAP population and considerable

non-monetized benefits may have led us to underestimate the benefits of the HealthyMatch program. The

large number of non-monetized benefits, the inferences we made about the RI SNAP population based on

national samples, and our omission of obesity as a health outcome from the model call for further data

collection and research. With more precise data on reduced RR of chronic disease resulting from

increased fruit and vegetable consumption, particularly for SNAP recipients, as well as monetization of

non-monetized benefits, a future cost-benefit analysis could return more robust estimates. We specifically

recommend non-self-reported data collection on the prevalence and incidence of CHD, diabetes, stroke

and cancer in the RI SNAP population, RR of these diseases for SNAP recipients, long-term health

outcomes for children whose fruit and vegetable consumption increases as a result of this incentive, time

costs related to assessing product eligibility, healthy food preparation, and transportation to grocery

retailers, as well as the association between fruit and vegetable consumption and reports of mental health

and well-being.

Much of the literature assumes that equalizing access to healthy foods will eliminate

socioeconomic disparities in nutritional consumption. However, studies indicate that it is socioeconomic

status itself, driven by education level, that causes these nutrition disparities. Even after controlling for

access issues, such as locations of grocery retailers, the research shows that more educated households

still purchase more healthful foods. Consequently, programs focused on expanding access to nutritious

foods may not immediately increase healthy food consumption among low-income households.77 As such,

we would also advise instituting a nutrition education program, spearheaded by RI CBOs, to support the

HealthyMatch program and encourage healthy behavior change. Though an education campaign would

incur additional costs, it may augment the effect size of the program and increase overall program

benefits.

20
ENDNOTES
1
Coleman-Jensen, Rabbit, Gregory, and Singh (2018).
2
U.S. Department of Agriculture Economic Research Service (2018): Definitions of Food Security
3
U.S. Department of Agriculture (2018): Supplemental Nutrition Assistance Program
4
Seligman, Laraia, and Kushel (2010)
5
Seligman, Bindman, Vittinghoff, Kanaya, and Kushel (2007)
6
Crews et al. (2014)
7
Gregory and Coleman-Jensen 2017
8
Ratcliffe and McKernan (2010)
9
Mancino, Gunthrie, Ver Ploeg, and Lin (2018); see also Leung et al. (2012)
10
Drewnowski and Specter (2004)
11
Olsho, Klerman, Wilde, and Bartlett (2016)
12
U.S. Census Bureau QuickFacts: Rhode Island. (n.d.). Retrieved from
https://www.census.gov/quickfacts/fact/table/ri/PST045217#PST045217
13
State of Rhode Island: Rhody Relish. (n.d.). Retrieved from http://dem.ri.gov/relishrhody/
14
Rhode Island Public Health Institute (2018): HEALTH Proposal: Development of State Nutrition Incentive Plan
15
Rhode Island Public Health Institute (2018): Food on the Move
16
Rhode Island Public Health Institute (2017): Annual Report 2017
17
Rhode Island Public Health Institute (2018): HEALTH Proposal: Development of State Nutrition Incentive Plan
18
Boardman, Greenberg, Vining, and Weimer (2017)
19
He, Hu, Colditz, Manson, Willett, and Liu (2004)
20
Phillips, Ratner, Buse, and Kahn (2014)
21
Stegenga, Kamphuis, King, Nazareth, and Geerlings (2012)
22
Campbell (2017)
23
Lakkur and Judd (2015)
24
Foulds (1958)
25
Bingham and Riboli (2004)
26
Hu, Rimm, Stampfer, Ascherio, Spiegelman, and Willett (2000); see also Miettinen, Karvonen, Turpeinen,
Elosuo, and Paavilainen (1972)
27
Khavjou, Phelps, and Leib (2016)
28
Dauchet, Amouyel, Hercberg, and Dallongeville (2006)
29
Khavjou, Phelps, and Leib (2016)
30
Dauchet, Amouyel, Dallongeville (2005)
31
American Diabetes Association. (2018)
32
Li, Fan, Zhang, Hou, and Tang (2014)
33
Short, Moran, and Punekar (2010)
34
Chang et al. (2004)
35
State of Rhode Island Department of Health (2015)
36
American Cancer Society (2017)
37
Riboli and Norat (2003)
38
Greenberg, Fournier, Sisitsky, Pike, and Kessler (2015)
39
Leung, Epel, Willett, Rimm, and Laraia (2014)
40
Rait, Walters, Griffin, Buszewicz, Petersen, and Nazareth (2009)
41
Saghafian, Malmir, Saneei, Milajerdi, Larijani, and Esmaillzadeh (2018
42
Mujci and Oswald (2016)

21
43
Mikolajczyk, El Ansari, and Maxwell (2009); see also McMartin, Jacka, and Colman (2013); see also El Ansari,
Adetunji, and Oskrochi (2014)
44
Blanchflower, Oswald, and Stewart-Brown (2013)
45
Florence, Asbridge, and Veugelers (2008); see also MacLellan, Taylor, and Wood (2008)
46
Morris, Evans, Tangney, Bienias, and Wilson (2006)
47
Loef and Walach (2012)
48
Steptoe, Perkins-Porras, Hilton, Rink, and Cappuccio (2004)
49
Palaniappan, Starkey, O'Loughlin, and Gray-Donald (2001)
50
Deshmukh-Taskar, Nicklas, Yang, and Berenson (2007); see also Steffen, Jacobs Jr, Stevens, Shahar, Carithers,
and Folsom (2003)
51
Shimotsu, Jones-Webb, Lytle, MacLehose Nelson, and Forster (2012); see also Steffen, Jacobs Jr, Stevens,
Shahar, Carithers, and Folsom (2003)
52
Loef and Walach (2012)
53
Florence, Asbridge, and Veugelers (2008); see also MacLellan, Taylor, and Wood (2008)
54
National Heart, Lung, and Blood Institute (2018): Coronary Heart Disease.
55
Mayo Clinic (2018): Type 2 diabetes.
56
Kissela et al. (2012)
57
National Cancer Institute (2015): Age and cancer risk.
58
Leung et al. (2013)
59
Amre et al. (2007)
60
Hannon, Rao, and Arslanian (2005)
61
St-Onge, Keller, and Heymsfield (2003)
62
Goran, Ball, and Cruz (2003)
63
Maynard, Gunnell, Emmett, Frankel, and Smith (2003)
64
Ibid
65
Craigie, Lake, Kelly, Adamson, and Mathers (2011).
66
te Velde, Twisk, and Brug (2007).
67
Blanchflower, Oswald, and Stewart-Brown (2013)
68
Florence, Asbridge, and Veugelers (2008); see also MacLellan, Taylor, and Wood (2008)
69
Morris, Evans, Tangney, Bienias, and Wilson (2006)
70
Loef and Walach (2012)
71
Mujcic and Oswald (2016)
72
Guh, Zhang, Bansback, Amarsi, Birmingham, and Anis (2009)
73
Solomon et al. (2008)
74
Bartlett and Abt Associates (2014)
75
Reece Lyerly: Personal communication, October 31, 2018.
76
Rhode Island Food Dealers Association (2018)
77
Handbury, Rahkovsky, and Schnell (2015)

22
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in relation to changes in fruit and vegetable intake and in plasma vitamins C and E in a randomised trial of
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 Appendix A: Demographics of SNAP Households in Rhode Island, 2016

In fiscal year (FY) 2016, Rhode Island (RI) provided approximately $0.27 billion dollars in

SNAP benefits to a monthly average of 171,055 people. This was a slight decrease from the monthly

average number of 175,025 RI SNAP beneficiaries in FY 2015.1 We used the monthly counts of SNAP

beneficiaries for calculations of the costs and benefits of HealthyMatch. The information in the tables

below, taken from the U.S. Department of Agriculture (USDA), represents the demographic

characteristics of the RI SNAP population by Congressional district in FY 2016.

1
United States Department of Agriculture Food and Nutrition Service, (2018). SNAP Community Characteristics -
Rhode Island. Retrieved from: https://www.fns.usda.gov/ops/snap-community-characteristics-rhode-island.

28
Table A.1
SNAP Household Characteristics: Rhode Island Congressional District 1

Makeup of Households SNAP Households

Total Households 36,433

Contains 1 or more people 60 years and over 35.6%

Contains child(ren) under 18 years 39.1%

Contains disabled individual(s) 54.6%

Income and Poverty Status in the Past 12 Months SNAP Households

Below poverty level 51.2%

Median household income (2016 dollars) $15,915

Race and Hispanic/Latino Origin of Householder SNAP Households

White 64.7%

Black or African American 15.6%

American Indian/Alaska Native 1.4%

Asian 1.7%

Native Hawaiian/Pacific Islander N/A

Some other race 11.3%

Two or more races 4.9%

Hispanic or Latino (of any race) 31.2%

Work Status SNAP Households

Families 20,747

No workers in the past 12 months 21.9%

1 worker in the past 12 months 50.8%

2 or more workers in the past 12 months 27.3%

Source: United States Department of Agriculture Food and Nutrition Service, (2018). SNAP Community
Characteristics - Rhode Island. Retrieved from: https://www.fns.usda.gov/ops/snap-community-characteristics-
rhode-island.

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Table A.2
SNAP Household Characteristics: Rhode Island Congressional District 2

Makeup of Households SNAP Households

Total Households 28,533

Contains 1 or more people 60 years and over 36.3%

Contains child(ren) under 18 years 39.1%

Contains disabled individual(s) 54.3%

Income and Poverty Status in the Past 12 Months SNAP Households

Below poverty level 47.9%

Median household income (2016 dollars) $18,446

Race and Hispanic/Latino Origin of Householder SNAP Households

White 73.3%

Black or African American 7.9%

American Indian/Alaska Native 1.0%

Asian 2.0%

Native Hawaiian/Pacific Islander N/A

Some other race 11.6%

Two or more races 4.2%

Hispanic or Latino (of any race) 20.4%

Work Status SNAP Households

Families 16,211

No workers in the past 12 months 23.9%

1 worker in the past 12 months 44.7%

2 or more workers in the past 12 months 31.3%

Source: United States Department of Agriculture Food and Nutrition Service, (2018). SNAP Community
Characteristics - Rhode Island. Retrieved from: https://www.fns.usda.gov/ops/snap-community-characteristics-
rhode-island.

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 Appendix B: Costs of the SNAP Program in Rhode Island

In fiscal year (FY) 2016, a total of $271,960,000 in SNAP benefits were issued in the state of

Rhode Island (RI) for 171,055 persons within 100,433 households. Total SNAP administrative costs in RI

amounted to $20,969,763 in FY 2016, with the state contributing a share of approximately $10,503,000

and the federal government contributing approximately $10,466,000. Total administrative costs per month

amounted to $26.08 per case.1

1
Food and Nutrition Service, Supplemental Nutrition Assistance Program, Program Accountability and
Administration Division (2017). Supplemental Nutrition Assistance Program, State Activity Report, Fiscal Year
2016. Retrieved from: https://fns-prod.azureedge.net/sites/default/files/snap/FY16-State-Activity-Report.pdf.

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 Appendix C: Food on the Move Site Locations

Table C.1
Site Locations of Food on the Move

Community Partner Market Site City/Town

Blackstone Valley BVCAP Community Center Pawtucket

Community Action Program

Bristol School Department Guiteras Elementary School Bristol

Brown University Brown University School of Public Health Providence

Central Falls Housing Forand Manor / Wilfred Manor Central Falls

Authority

Charlesgate Living Charlesgate East Providence

Coventry Housing Authority Knotty Oak Village / North Road Terrace Coventry

Franklin Court Independent Franklin Court Independent Living Bristol

Living

Pawtucket School Department Cunningham School Pawtucket

Pawtucket Housing Authority Fogarty Manor / Galego Court Pawtucket

Providence Public Schools D’Abate Elementary School Providence

Providence Housing Carroll Towers / Dexter Manor / Dominica Providence

Authority Manor / Parenti Villa

Town of Bristol Bristol Town Beach Bristol

TriCounty Community Action TriCounty Community Action Partnership North Providence

Partnership

West Warwick Housing West Warwick Manor West Warwick

Authority

West Warwick Public Library West Warwick Library West Warwick

Woonsocket Housing Kennedy Manor Woonsocket

Authority

Source: Rhode Island Public Health Institute (RIPHI)

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 Appendix D: Proposal for the Development of a State Nutrition Incentive Plan

This proposal was prepared by the Rhode Island Public Health Institute (RIPHI).

Summary
Access to healthy food represents a significant social determinant for health outcomes, impacting
nutrition-related chronic disease burdens for residents across Rhode Island. Low-income Rhode Islanders
face significant barriers to accessing healthy food, including limited geographic access to stores selling
healthy food, limited financial access to afford healthy food, and retail store environments that lack tools
to promote healthy food. RIPHI proposes to use stakeholder involvement to develop a plan to strengthen
healthier food access and sales in retail venues and community venues through increased availability,
improved pricing, placement, and promotion. The process will include public and private sector partners,
and will be coordinated with the Rhode Island Food Strategy and the Governor’s Hunger Elimination
Task Force recommendations.

Food Insecurity
Food insecurity poses a significant public health threat across the nation. The risk of food insecurity is
disproportionately borne by low-income Americans, who correspondingly live with higher rates of
nutrition-related chronic disease, including diabetes, obesity, and heart disease. Recent pilot programs to
incentivize the purchase of fruits and vegetables pose an exciting opportunity to address the disparities in
food access.

Incentivizing Healthy Eating

Although low-income Rhode Islanders face disproportionate risk of nutritional insecurity, Rhode
Islanders across the income spectrum fail to meet recommended daily intake of fresh fruits and
vegetables. Barriers within retail environments and community settings currently disincentive healthy
eating, where the most affordable, available choices are often those with the least nutritional value. Retail
environments prioritize products with the highest profit margin and the strongest relationship with food
suppliers, who often pay “stocking fees” to ensure preferential treatment in retail settings. Multiple
strategies could shift these retail environments, including improved supply chains to procure healthy food,
“healthy checkout” strategies to place healthy food closer to the register, and increased marketing support
to promote healthy food. However, based on consumer survey data from Food on the Move, one of the
most significant barriers for shoppers to buy fresh fruits and vegetables is the cost of produce.

Our survey data shows that families do want to be purchasing fresh food, and will do so when it is made
affordable. One demonstrated strategy to increase fruit and vegetable purchases is Nutrition Incentives,
which lower the cost of fresh food by offering a discount or “match” for shoppers who qualify. RIPHI
believes that improving the pricing of fruits and vegetables for shoppers who qualify by expanding
purchasing power will increase demand for these products in local retail environments. When more
customers can afford the healthier choice, RIPHI believes that retailers will respond to this demand by
undertaking the aforementioned strategies to also improve availability, placement, and promotion of these
products within their stores.

We have already seen major retailers, including Stop & Shop and CVS, two dominant retailers in the
state, renovate their store environments in recent years to account for increased demand for healthy food
for their customers. However, these retail environment changes still leave disparities in affordability of
healthy food for low-income Rhode Islanders. Nutrition Incentives represent an evidence-based strategy
to ensure that this increased purchase of fresh fruits and vegetables is shared by all Rhode Islanders. To
date, most nutrition incentive programs focus on populations enrolled in the Supplemental Nutrition

33
Assistance Program (SNAP). Based on demonstrated impact from long-standing programs in the state,
RIPHI believes that implementing and scaling a SNAP Nutrition Incentive Program can have long-
standing impact on improving population healthy by shifting the economic determinants of consumers’
food choices in retail settings.

SNAP
The Supplemental Nutrition Assistance Program (SNAP) represents one of the most widespread public
interventions to alleviate food insecurity, enrolling 42 million individuals and distributing over $63
billion nationwide in 2017. In Rhode Island, households under 130% of Federal Poverty Line rely on
SNAP benefits for an average of 44% of the meals consumed. However, participant data shows that
SNAP benefits last only through the early part of the month; these funds are insufficient to meet need in
household food budgets. Lack of funds prevent higher-risk households from using SNAP benefits on
fresh fruits and vegetables and other high-nutrient food. As SNAP funds are depleted at the end of the
month, households may incur credit card debt to pay grocery bills, rely on emergency food systems that
often cannot provide fresh food, and may have to choose between household needs including paying for
food or paying rent, or paying for food or paying for medicine.
SNAP Incentives
Nutrition incentives represent an innovative, market-based solution to food insecurity that addresses the
financial barrier to healthy food access. Nutrition incentives direct funding toward at-risk households to
purchase fruits and vegetables. The most common form of nutrition incentives are tied to SNAP benefits;
SNAP participants receive a financial benefit to stretch their SNAP dollars further when they spend their
benefits on fruits and vegetables. This model has been tested for over a decade, since Wholesome Wave
initiated SNAP-doubling programs in five states across the country. Since then, this model has expanded
to hundreds of pilots across the country. In 2014, this program was incorporated into the United States
Department of Agriculture (USDA) Farm Bill, which allocated $100 million towards the “Food Insecurity
Nutrition Incentive Program” (FINI). These funds were competitively awarded to grantees across the
country to test and implement a wide range of program designs. As of December 2017, 90 organizations
in 39 states have received federal funds through this program. These incentives are distributed through
supermarkets, grocery stores, neighborhood food stores, farmers’ markets, farm stands, community
supported agriculture (CSA) programs, and mobile markets. Preliminary research indicates positive
results, showing increased fruit and vegetable purchase, increased fruit and vegetable consumption,
improved health outcomes, and decreased healthcare utilization. Additional funds toward food purchases
also have a multiplier effect on economic development and jobs; every dollar invested in the food
economy is estimated to generate $1.79 of economic activity. This contributes to much-needed job
creation in the state overall.
Scaling Up
Currently, both publicly and privately funded nutrition incentive programs are implemented by grantees
in 31 states across the country. In 2014, these programs served an estimated 50,000 consumers,
representing only 0.1% of the consumers using SNAP benefits. Most current incentive programs are
offered at farmers markets. However, only 3.6% of SNAP benefits are spent at farmers markets. To scale
this program, retail grocers and supermarkets must also be incorporated into the national model. Building
on these lessons learned, this program can be scaled up to become a coordinated program with national
reach.
Currently, many programs are funded through the Food Insecurity Nutrition Incentive Program, allocated
through the 2014 Farm Bill. However, this funding has now been allocated and faces vulnerability of
being cut in the upcoming 2018 Farm Bill. A sustainable program must identify long-term sources of
funds. These may be diverted through Medicaid, Department of Agriculture, or other federal funds. One

34
method to quickly scale a national program would be to encourage private investment through a Pay For
Success model, which has been used to fund programs to address social needs around housing,
incarceration-recidivism, and education. This model would allow investors to provide up-front capital and
would recoup the savings achieved through decreased healthcare utilization.
The Rhode Island Context
Rhode Island’s recent Food Strategy, released by the office of Governor Gina Raimondo, identified
nutrition incentives as a key objective to address food insecurity in the state. The Strategy lists incentive
funds as a central metric to track over time. The Hunger Elimination Task Force, led by Director of Food
Strategy Sue AnderBois, has identified increased purchasing power for low-income Rhode Islanders to
buy fruits and vegetables as a top priority.
Rhode Island has a strong track record running long-standing nutrition incentive pilot programs. Rhode
Island has piloted two nutrition incentive models through Farm Fresh Rhode Island, which distributes
incentives for shoppers at farmers markets, and Rhode Island Public Health Institute, which distributes
incentives to shoppers at the Food on the Move mobile markets. These two statewide programs distribute
over $200,000/year in incentives. Lessons learned from these pilots, as well as from other pilots across
the country, can inform efforts to coordinate and expand this programs to serve more SNAP shoppers
throughout the state.
Rhode Island is poised to leverage existing partnerships to build a coalition-driven program that serves
the needs of diverse stakeholders. Long-standing collaboration with local pilot organizations RIPHI and
Farm Fresh RI will set a baseline for lessons learned in previous programs. Collaborations with public
and private policy stakeholders including the State Director of Food Strategy, the Governor’s Hunger
Elimination Task Force, the Department of Health’s Health Equity Zones, the Department of Human
Services, the State Innovation Model, the University of Rhode Island’s SNAP Outreach Program, and the
Rhode Island Food Policy Council will help convene decision makers to provide input, conduct outreach,
and identify capacity to support this program. National partnerships with Wholesome Wave, Fair Food
Network, AARP Foundation, the United States Department of Agriculture, the Benefits Data Trust, the
Massachusetts Food System Collaborative, and other organizations will help us draw from lessons
learned around the country to build an evidence-based design for the Rhode Island context. Finally,
collaboration with Social Enterprise Greenhouse, Social Finance US, and private foundations including
AARP Foundation can help identify sustainable funding models to support this important program.
Rhode Island is poised to develop the first statewide nutrition incentive program in the country. Based on
pilot data, we believe this program will have widespread impact on population health, will increase
purchasing at local businesses, will create jobs due to increased economic activity, and will result in
healthcare cost savings long-term.
Deliverables
RIPHI proposes to use April – September 2018 to complete the following steps in the planning and
coalition building process in service of the Rhode Island Nutrition Incentive Program:

Identify global research already evaluating related programs in other states and nations

Identify barriers and opportunities in Rhode Island by working with grocery retailers, Rhode Island Food
Policy Council, Director of Food Strategy Sue Anderbois, and other stakeholders mentioned above.

Conduct feasibility study for program implementation in Rhode Island.

35
Conduct cost-benefit analysis to identify necessary program investments and model cost offsets from
economic impact and healthcare utilization savings.

Engage coalition stakeholder group that could serve as advocates and provide ongoing input to
implement and expand program.

Engage funders who could provide initial capital to support the Rhode Island Nutrition Incentive
Program.

Conclusion
Nutrition Incentives represent an important public health strategy to address food insecurity and improve
health outcomes for nutrition-related chronic disease including diabetes, heart disease, and obesity. Rhode
Island is poised to develop the first statewide comprehensive nutrition incentive program in the country.
Building upon on existing strong cross-sector partnerships and a longstanding track record for existing
pilot programs, as well as recent initiative from the Office of the Governor, Rhode Island could serve as a
national model for best practices and improved population health by enacting this landmark effort. Rhode
Island Public Health Institute has been a central coalition member in both testing existing pilot programs
as well as building cross-sector coalitions in this effort thus far. RIPHI proposes to build a comprehensive
nutrition incentive plan, including a technical feasibility study, population health analysis, and cost-
benefit analysis. This document will enable us to pursue funding and coordinate partners in order to build
this innovative public health measure into a sustainable statewide program.

36
 Appendix E: Overview of the Healthy Incentives Pilot

This appendix includes a summary of the Healthy Incentives Pilot (HIP), a program designed to

encourage SNAP households to purchase more fruits and vegetables. The program offered a discount on

fresh fruits and vegetables to SNAP recipients, thus incentivizing participants to increase the amount of

consumption. This information provided a framework for the design and rationale of the proposed

HealthyMatch pilot program.

Program Format
According the HIP Summary, the pilot was implemented by the Massachusetts Department of

Transitional Assistance (DTA) in Hampden County, Massachusetts. The county includes “urban, rural

and suburban areas with approximately 55,000 SNAP households.”1 From that population, 7,500

Hampden County SNAP households were randomly selected to participate in HIP. The remaining

households continued to receive their usual SNAP benefits.

Those who were randomly selected to participate received the following incentive: for each dollar

of SNAP benefits recipient households spent on identified fruits and vegetables at participating retailers,

SNAP beneficiaries received a 30-cent incentive. The incentive was applied to their SNAP Electronic

Benefit Transfer (EBT) card. To prevent misuse, the incentive was limited to $60 per month per

household. This limit also ensured that incentive payments, in total, did not exceed $2 million. The limit

was not found to impede household purchases of fruits and vegetables as few households reached it. HIP

was implemented over three months, in three waves, with approximately equal numbers of households

able to begin receiving incentives in each wave. Once beginning to receive incentives, participants earned

incentives for twelve months.

Evaluation of HIP
According to the HIP summary, during the course of the pilot, data were collected through

telephone surveys, EBT transactions, retailer surveys, review of administrative cost data, and interviews

1
Bartlett, Susan, Jacob Klerman, Lauren Olsho, et al. (2014) Evaluation of the Healthy Incentives Pilot (HIP): Final
Report. Prepared by Abt Associates for the U.S. Department of Agriculture, Food and Nutrition Service. Retrieved
from: https://fns-prod.azureedge.net/sites/default/files/ops/HIP-Final_Findings.pdf.

37
with key stakeholders. Telephone interviewers conducted dietary recall interviews with a random sample

of 5,000 households, including both HIP and non-HIP households, to obtain detailed information on food

and beverage consumed in the 24 hours prior to the interview. EBT transaction-level data were collected

for all SNAP households in the county.

Findings
Fruit and Vegetable Consumption
Researchers found a 26 percent increase in consumption, or almost a quarter of a cup, for HIP

participants over non-HIP participants. This finding was statistically significant. The impact of HIP on the

consumption of fruits and vegetable did not vary by any demographic characteristic examined, the

presence of children in the household, employment status, age or the amount of the household’s benefit.

Researchers also found that HIP participants increased their consumption of vegetables more than fruits.

The HIP Summary reports that about 55 percent of the HIP effects were from greater consumption of

vegetables. The increase in vegetables included dark green vegetables, red/orange vegetables, and “other”

vegetables (e.g., celery, cucumbers, mushrooms, green beans, onions, asparagus).

Behavioral Changes
Findings suggest HIP was more successful in strengthening positive attitudes toward fruits and

vegetables among individuals who already regularly consumed fruits and vegetables. Evidence also

suggests that changed attitudes may play a role in increased consumption as well.

Spending
The HIP Summary indicated the households more likely to earn HIP incentives were those with

higher SNAP benefits, children in the household, and Hispanic or Asian household heads. Throughout the

pilot, the average monthly purchases by HIP households were similar and less than anticipated. HIP

households spent about $12 on identified fruits and vegetables in an average month from participating

stores. This represented about 5 percent of their SNAP benefits. Self-reports of spending indicate HIP

households spent $6.15 or 8.5 percent more than non-HIP households on fruits and vegetables.

38
Figure E.1
Differences in Household Purchases Using HIP Incentives

Source: Bartlett, Susan, Jacob Klerman, Lauren Olsho, et al. (2014) Evaluation of the Healthy Incentives Pilot
(HIP): Final Report. Prepared by Abt Associates for the U.S. Department of Agriculture, Food and Nutrition
Service. Retrieved from: https://fns-prod.azureedge.net/sites/default/files/ops/HIP-Final_Findings.pdf.
Retailers
Store operation were minimally impacted by HIP. Retailers indicated HIP purchases were easy to

process, with “over 90 percent reporting no change in check-out time.”2 Among the smaller retailers,

those without Integrated Electronic Cash Register (ICER) installed, reported that HIP purchases were

hard to process because they had to manually separate them out. SNAP spending largely occurred in

supermarkets, superstores and grocery stores. Those retailers that participated in HIP saw HIP-related

spending increases. Retailers also reported stocking more fruits and vegetables after HIP began.

Implementation Costs and Processes

Total costs for HIP were $4.4 million. Systems level changes accounted for about half of the total

costs, while incentive payments to program participants accounted for 6 percent. The remaining costs

came from retailer recruitment, participant notification and training, program administration and program

evaluation. The system changes required developing and testing software over roughly 15 months on a

tightly coordinated schedule. Participating retailers noted that it generally requires 18-24 months to make

2
Ibid.

39
the type of system changes needed to accommodate HIP. Several non-participating retailers indicated that

they would have been more willing to participate in the pilot if HIP were a permanent part of SNAP. Not

all SNAP households had similar access to participating stores, which likely influenced the impacts of

HIP.

40
 Appendix F: Cost Estimates Based on the Healthy Incentives Pilot

Cost estimates were calculated based on the estimations in the Healthy Incentives Pilot (HIP)

Report. Appropriate adjustments and uncertainties were included in the model to account for differences

between HIP and the HealthyMatch program. We removed the “Evaluation Support” and “Unassigned”

line items in our replicated budget after determining they were not relevant to the implementation of

HealthyMatch.

Table F.1
Implementation Costs of the Healthy Incentives Pilot

Source: p. 176, Bartlett, S., & Abt Associates. (2014). Evaluation of the Healthy Incentives Pilot (HIP), Final
Report. United States Department of Agriculture, Food and Nutrition Service, Office of Policy Support. Retrieved
from: https://fns-prod.azureedge.net/sites/default/files/ops/HIP-Final.pdf.

Take-Up Rate Adjustments

According to the HIP report, 34 percent of HIP households had no HIP purchases in a given

month. Based on this estimate, we assumed a 66 percent HealthyMatch take-up rate among Rhode Island

(RI) SNAP households when calculating the annual provision of benefits. To account for this estimated

take-up rate, we multiplied our estimated total number of RI SNAP households by 0.66. We calculated

41
the total RI SNAP households by assuming a uniform distribution between estimates of RI SNAP

beneficiaries from 2015 (175,025) and 2016 (171,055).1,2

Inflation Adjustments
Costs in the HIP Report are listed in 2013 dollars; therefore, we adjusted all implementation cost

estimates to 2018 dollars to align with the rest of our model. These adjustments were performed using the

most recent Consumer Price Index (CPI) available from the Bureau of Labor Statistics from October 2018

(252.885), as well as the baseline CPI from December 2013 (233.049).3,4

Adjustments for HealthyMatch/HIP Programmatic Differences

System Design, Development, and Testing: These costs were adjusted based on the type of grocery store

in question. More details on the price differences across grocery store types can be found in Table F.2.

Household Recruiting and Customer Service: See Appendix G.

Retailer Recruiting: Adjustments were made based on the number of grocery stores in RI expected to

participate in HealthyMatch: 130 grocery stores participated in HIP. There are an estimated 300 grocery

stores in RI.

Community Relations: No additional adjustments were performed outside of inflation adjustments.

Training: No additional adjustments were performed outside of inflation adjustments for the initial

training costs in the first year of implementation. Each subsequent year of our model adjusts costs to

account for employee turnover in the retail trade industry. Using data from the Bureau of Labor Statistics

from 2013 to 2017, we calculated an average annual separation rate of 53.58 percent for the retail trade

1
United States Department of Agriculture, Food and Nutrition Service (2018, January 19). SNAP Community
Characteristics - Rhode Island. Retrieved from: https://www.fns.usda.gov/ops/snap-community-characteristics-
rhode-island.
2
United States Department of Agriculture, Food and Nutrition Service. (2018, January). Profile of SNAP
Households: Rhode Island Congressional District 1. Retrieved from:
https://fns.prod.azureedge.net/sites/default/files/ops/RhodeIsland.pdf.
3
United States Department of Labor, Bureau of Labor Statistics (2018). Consumer Price Index for All Urban
Consumers (CPI-U): U.S. City Average, by Expenditure Category. Retrieved from:
https://www.bls.gov/news.release/cpi.t01.htm.
4
United States Department of Labor, Bureau of Labor Statistics (2014). Consumer Price Index - December 2013
(USDL-14-0037). Retrieved from: https://www.bls.gov/news.release/archives/cpi_01162014.pdf.

42
industry.5 This calculated rate was then used to project ongoing training costs for new employees hired by

grocery stores participating in HealthyMatch.

General Administration: No additional adjustments were performed outside of inflation adjustments.

Uncertainty Parameters
For each cost estimate used in the model, we included a +/- 10 percent uncertainty parameter, in

order to account for any additional differences between HIP and HealthyMatch not already included in

our adjustments. Adjusted HIP incentives account for programmatic differences in the populations

receiving incentives and the difference in the amount of incentive delivered at each SNAP transaction.

Table F.2
Estimated Cost of Integrated Electronic Cash Register System Modifications for Nationwide Expansion

Source: p. 176, Bartlett, S., & Abt Associates. (2014). Evaluation of the Healthy Incentives Pilot (HIP), Final
Report. United States Department of Agriculture, Food and Nutrition Service, Office of Policy Support. Retrieved
from: https://fns-prod.azureedge.net/sites/default/files/ops/HIP-Final.pdf.

Table F.3
Total and Per Household Cost of Healthy Incentives Pilot Incentives

Source: Ibid.

HealthyMatch/HIP Adjustment
While HIP provided a $0.30 match, HealthyMatch provides a $1.00 match with each SNAP

purchase. We accounted for this difference by assuming a 1.5 effect size of the subsidy. We took this

from academic literature on price elasticities of fruit and vegetable spending in response to changes in

5
United States Department of Labor, Bureau of Labor Statistics (2018). Annual Total Separations Rates by Industry
and Region, Not Seasonally Adjusted. Retrieved from: https://www.bls.gov/news.release/jolts.t16.htm.

43
price. The HIP report utilizes a 0.64 - 0.67 estimate of the price elasticity of fruit and vegetable purchases.

We use this information to estimate that if the effective price of fruits and vegetables decreases 50 percent

through the use of the one-to-one HealthyMatch, we would anticipate that behaviorally, fruit and

vegetable spending would increase by a factor of 1.5, found by taking the reciprocal of 0.64. This falls in

line with the academic literature that suggests that the pure price effect of an incentive or subsidy is not

the same magnitude as that subsidy. We then calculated HealthyMatch’s Average Incentive per

Household per Month by multiplying the effect size by the “$ per HIP household per month” estimate

provided in Table F.3.

SNAP Household Adjustment

Scalar adjustments were made based on number of SNAP households receiving benefits in RI.

We generated an estimate of SNAP beneficiaries in RI by varying the 2016 SNAP average monthly

household estimate by 10%. This calculation was performed to account for expected fluctuations in

SNAP participation that occur over the course of a given year. Nutrition incentive cost projections were

then scaled to account for population differences between HealthyMatch and HIP.

Annual Nutrition Incentive Adjustment Calculation:

Example Calculation:

12 · 5.94 · 0.66 · 64,966 = $3,056,312

Where:
Average Incentive per Household per Month = $5.94
Percent of SNAP Households per Month Redeeming Incentives = 0.66
RI SNAP Households = 64,966

44
 Appendix G: Participant Recruitment Costs

We modeled the costs of HealthyMatch off of the Healthy Incentives Pilot (HIP). HIP participants

received seven to eight letters throughout their participation in the program including the following:

● Three notification letters sent prior to the start date

● A letter containing a list of all participating retailers and farmers markets
● A mailing containing a description of the program in “user-friendly” terms
● A mailing customized to each participant informing them of how many benefits they had accrued
and had the potential to earn in the next month, as well as several recipe cards
● A mailing with an updated list of participating retailers and farmers markets with closing dates
● A final mailing for participants in the second and third wave of the pilot informing them of the
end date of their benefits.1

Our model assumes that participants in HealthyMatch will receive information about the program and

SNAP recertification materials annually.2 Due to overturn in SNAP program participation, we estimated

recertification materials would be sent to 1.5 times the average number of Rhode Island (RI) SNAP

households.3 We estimated that this mailing would be approximately eight pages printed in color, front

and back, and would include the following information: program description, list of participating retailers,

and frequently asked questions (FAQs). Program description and FAQs would be provided in both

English and Spanish. We assumed the cost of this mailing would be approximately equivalent to one of

the mailings sent by HIP, based on comparisons from online printing cost estimators.4 The description of

the HIP mailings indicated that the third mailing included an Electronic Benefits Transfer (EBT) card

sleeve that contained information on eligible foods. We assumed this mailing would cost two to three

times of that of the other mailings. We divided the total HIP recruitment costs dedicated to direct mailings

1
Bartlett, S., & Abt Associates. (2014). Evaluation of the Healthy Incentives Pilot (HIP), Final Report. United
States Department of Agriculture, Food and Nutrition Service, Office of Policy Support.
2
Rhode Island Department of Human Services. SNAP Rules and Regulations. Retrieved from:
http://www.dhs.ri.gov/Regulations/218-RICR-20-00-1SNAPRevisionsAdoptionSOS.pdf.
3
USDA. Dynamics of Supplemental Nutrition Assistance Program Participation from 2008 to 2012. Retrieved
from: https://fns-prod.azureedge.net/sites/default/files/ops/Dynamics2008-2012.pdf.
4
Staples. Color Copy Cost Estimator. Retrieved from:
https://documents.staples.com/ASP1/SmartStore.aspx?QxwAkrpHdoTpJQ4/NUWILGhXVTrEwdxHw8Lxmdsq0ed
5ORARK3ida94N9LnWhlVT#!/Storefront/Color/1205/product/Customize.

45
by seven and varied the weighting of the cost of the third mailing by factors of two and three. Below are

steps used to calculate the cost of the HealthyMatch recruitment mailing.

Calculation of Participant Recruitment Costs

• Determined the portion of HIP participant recruitment costs dedicated to direct mailings:
$118,058 · 0.75 = $88,543.50
• Inflated this expenditure by the ratio of the 2018 and 2013 Consumer Price Indices (CPI):
(252.885 ÷ 233.049) · $88,543.50 = $96,079.89306
• Divided this amount by the number of HIP participants to get a per-participant mailing cost for all
seven mailings:
$96,079.89306 ÷ 7,500 = $12.81
• Calculated per-mailing cost, assuming all mailings cost the same to print and send:
$12.81 ÷ 7 = $1.83
• Assuming Mailing #3 (which includes the pamphlet) is the most expensive by a factor of two,
calculated the per-participant mailing cost of the other six mailings:
$12.81 ÷ 8 = $1.60
• Assuming Mailing #3 is the most expensive by a factor of 3, calculated the per-participant
mailing cost of the other six mailings:
$12.81 ÷ 9 = $1.42
• Using the number of RI SNAP households, estimated per household costs of the mailings:5
$1.83 · 64,966 = $118,887.78
$1.60 · 64,966 = $103,945.60
$1.42 · 64,966 = $92,251.72
Table G.1
Estimated Mailing Costs

Total Costs

Cost Variation Costs per SNAP Household Cost of mailings · 1.5

Assuming all equal $118,887.78 $173,831.67

Assuming factor of 2 $103,945.60 $155,918.40

Assuming factor of 3 $92,251.72 $138,377.625

5
USDA. Profile of SNAP Households. Retrieved from: https://fns-
prod.azureedge.net/sites/default/files/ops/RhodeIsland.pdf.

46
 Appendix H: Costs and Benefits of HealthyMatch by Year

Table H.1
Costs and Benefits of HealthyMatch by Year

47
48
 Appendix I: Prevalence and Incidence of Diseases

Prevalence refers to the number of current cases of a disease at or during a given time, while

incidence refers to the number of new cases of a disease at or during a particular time period (new cases

of the condition).6 As we were unable to locate specific disease prevalence and incidence estimates in the

literature for the Rhode Island (RI) SNAP population, we utilized general disease prevalence and

incidence estimates for the United States population as a whole. We used these estimates of prevalence

and incidence of various diseases to calculate the avoided costs of said diseases attributable to

HealthyMatch.

Prevalence of Chronic Disease

All prevalence data, excluding that for depression, were collected from a July 2017 U.S.

Department of Agriculture (USDA) report, “Food Insecurity, Chronic Disease, and Health Among

Working-Age Adults.”7 The report notes that food insecurity is generally associated with higher

prevalence of chronic diseases. The report uses five years of data from the National Health Interview

Survey (NHIS), including a sample of 41,854 adults in households “with income at or below 200 percent

of the Federal Poverty Level.”8 The survey measures food security status using questionnaire responses

regarding household behaviors. For the purposes of this analysis, we use the low and very low food

secure populations as a proxy for the population of SNAP beneficiaries.

The USDA report provides prevalence of chronic illnesses by food security status. Prevalence

among low and very low food insecure adults was calculated by weighting the prevalence estimates by

the proportion of individuals reported in each food security category, and subsequently adding them

together. Estimates of prevalence for low food security, very low food security, and the calculated low

and very low food security categories are reported below.

6
Centers for Disease Control and Prevention (May 18, 2012). Lesson 3: measures of risk. Principles of
Epidemiology in Public Health Practice, Third Edition: An Introduction to Applied Epidemiology and Biostatistics.
Retrieved from: https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson3/section2.html.
7
Gregory, C. A., & Coleman-Jensen, A. (2017). Food Insecurity, Chronic Disease, and Health Among Working Age
Adults, ERR-235. U.S. Department of Agriculture, Economic Research Service. Retrieved from:
https://www.ers.usda.gov/webdocs/publications/84467/err-235.pdf?v=%A042942.
8
Ibid.

49
Table I.1
Proportion of Adults with Chronic Illnesses (Excluding Depression) by Food Security Status

Food Security Status

Low and very low food

Disease Category Low food security Very low food security
security

Diabetes 0.111 (0.005) 0.140 (0.006) 0.125

Coronary Heart Disease 0.037 (0.003) 0.056 (0.005) 0.046

Stroke 0.034 (0.003) 0.050 (0.004) 0.0417

Cancer 0.047 (0.003) 0.058 (0.004) 0.058

N 6,286 5,802 12,088

Source: Gregory, C. A., & Coleman-Jensen, A. (2017). Food Insecurity, Chronic Disease, and Health Among
Working-Age Adults, ERR-235. U.S. Department of Agriculture, Economic Research Service. Retrieved from:
https://www.ers.usda.gov/webdocs/publications/84467/err-235.pdf?v=%A042942.

Incidence of Diabetes
Data on diabetes incidence were collected from the Centers for Disease Control and Prevention

(CDC), which utilized the 2013–2015 NHIS, 2011–2014 National Health and Nutrition Examination

Survey (NHANES), and 2015 U.S. Census Bureau data. The estimated incidence of diabetes amongst

U.S. adults in 2015 was 6.7 cases per 1,000 people, or 0.0067.9 Using 95% confidence interval (CI), we

computed a standard error (SE) of 0.00028061.

Incidence of Coronary Heart Disease

Data on coronary heart disease (CHD) incidence were collected by the American Heart

Association’s (AHA) Heart Disease and Stroke Statistics - 2017 Update.10 In 2017, the AHA estimated

that 695,000 Americans will have a new coronary event each year. U.S. Census Bureau data indicates the

adult population in 2017 was 252,406,635.11 We divided the number of new coronary events by the 2017

population to determine an approximate incidence of new CHD events of 0.00275349. To account for
9
Centers for Disease Control and Prevention (2018). Incidence of Diagnosed Diabetes. Retrieved from:
https://www.cdc.gov/diabetes/data/statistics-report/incidence-diabetes.html.
10
American Heart Association. Heart Disease and Stroke Statistics—2017 Update A Report From the American
Heart Association (Rep.). (2017). Retrieved from:
https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000485.
11
US Census Bureau. (2017, July). Data. Retrieved from:
https://www.census.gov/quickfacts/fact/table/US/PST045217.

50
uncertainty in our estimate, we used the AHA’s reported incidence rates of age-adjusted first myocardial

infarction or fatal CHD rates per 1,000 people from the National Heart, Lung, and Blood Institute

(NHLBI)-sponsored Atherosclerosis Risk in Communities (ARIC) study, which conducted surveillance

between 2003 and 2013. ARIC reported incidence rates per 1,000 as 3.8 for white males, 6.6 for black

males, 2.2 for white females, and 4.3 for black females.12 Next, we generated a pooled estimate of the

ARIC rates weighted by the proportion of white and black individuals in the RI SNAP population and the

proportion of men and women in the national SNAP population.13,14 This estimate of incidence of 3.08414

per 1000 was used to vary our estimate by 12 percent.

Incidence of Stroke
Data on the nationwide incidence of stroke were collected from the AHA’s Heart Disease and

Stroke Statistics - 2017 Update.15 The estimated number of first stroke events in 2014 was approximately

610,000. According to 2014 U.S. Census Bureau data, the national adult population was roughly

72,008,690.16 By dividing the number of stroke events by the adult population, we calculated an incidence

of stroke of 0.0084712. To account for variation, we used the AHA’s estimates of age-adjusted stroke

incidence from 2004, which were reported as 5.1 cases per 1,000 women and 5.3 cases per 1,000 men.

Next, we generated a pooled estimate of these rates weighted by the proportion of males and females in

the RI SNAP population.17 This estimate of incidence was used to vary our estimate by 38 percent.

12
American Heart Association. Heart Disease and Stroke Statistics—2017 Update A Report From the American
Heart Association (Rep.). (2017). Retrieved from:
https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000485.
13
United States Department of Agriculture Food and Nutrition Service (2018). SNAP Community Characteristics -
Rhode Island. Retrieved from: https://www.fns.usda.gov/ops/snap-community-characteristics-rhode-island.
14
United States Department of Agriculture. Characteristics of Supplemental Nutrition Assistance Program
Households: Fiscal Year 2015. (2016). Retrieved from: https://fns-
prod.azureedge.net/sites/default/files/ops/Characteristics2015.pdf.
15
American Heart Association (2017) Heart Disease and Stroke Statistics—2017 Update A Report From the
American Heart Association (Rep.).
Retrieved from: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000485.
16
US Census Bureau. (2017, May 09). Data.
Retrieved from: https://www.census.gov/data/tables/2014/demo/popproj/2014-summary-tables.html.
17
United States Department of Agriculture Food and Nutrition Service (2018). SNAP Community Characteristics -
Rhode Island. Retrieved from: https://www.fns.usda.gov/ops/snap-community-characteristics-rhode-island.

51
Incidence of Cancer
Data on the incidence of cancer were collected by the RI Department of Health (HEALTH) in

2015 and by the American Cancer Society (ACS) in 2017. The estimated incidence of cancer in 2015

among Rhode Islanders was 458.1 per 100,000 people, or 0.4581 percent.18 According to the ACS, the

estimated incidence of cancer in 2017 was 5,870 people.19 RI’s population is 1,006,000, resulting in an

incidence of 0.5845 percent. A uniform distribution was created to capture both estimates in the analysis.

Prevalence & Incidence of Depression

Data on the prevalence of depression in the SNAP population were collected from a study using

the 2005-2010 NHANES.20 Prevalence of depression in the SNAP population was 12.8 percent, according

to a nine-item Patient Health Questionnaire that defined depression as greater than a score of 10. The

overall prevalence of depression in the general population was 9.3 percent. To determine SE, we utilized

a CDC study on prevalence of depression using data from the Behavioral Risk Factor Surveillance

System (BRFSS), which estimated depression prevalence at 9 percent, or 0.09.21 Unlike the Leung et al.

study, this analysis was not specific to the SNAP population. Using 0.09 as the lower bound, we applied a

CI of 0.09-0.166 and a SE of 0.0194.

Data on incidence of depression was collected from a United Kingdom study by Rait et al.

(2009), utilizing a primary care database.22 Data on incidence of depression were relatively rare, due to

the nature of the disease. Individuals can move in and out of depression, experiencing multiple depressive

episodes of varying lengths over their lifetimes.23 Incidence of depression decreased from 22.5 diagnoses

18
State of Rhode Island Department of Health (2015). Cancer Incidence Trend Data. Retrieved from:
http://health.ri.gov/data/cancer/trend/.
19
American Cancer Society (2017). Cancer Facts & Figures 2017. Atlanta: American Cancer Society. Retrieved
from: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-
figures/2017/cancer-facts-and-figures-2017.pdf.
20
Leung, C. W., Epel, E. S., Willett, W. C., Rimm, E. B., & Laraia, B. A. (2014). Household Food Insecurity Is
Positively Associated with Depression among Low-Income Supplemental Nutrition Assistance Program Participants
and Income-Eligible Nonparticipants. The Journal of Nutrition, 145(3), 622-627.
21
Centers for Disease Control and Prevention (CDC. (2010). Current depression among adults--United States, 2006
and 2008. MMWR Morbidity and Mortality Weekly Report, 59(38), 1229-1235.
22
Rait, G., Walters, K., Griffin, M., Buszewicz, M., Petersen, I., & Nazareth, I. (2009). Recent trends in the
incidence of recorded depression in primary care. The British Journal of Psychiatry, 195(6), 520-524.
23
Solomon, D. A., Keller, M. B., Leon, A. C., Mueller, T. I., Lavori, P. W., Shea, M. T., ... & Endicott, J. (2000).
Multiple recurrences of major depressive disorder. American Journal of Psychiatry, 157(2), 229-233.

52
per 1000 people in 1996 to 14 diagnoses per 1000 people in 2006. Consequently, we varied depression

incidence using a CI of 0.085-0.225 and a SE of 0.0357.

53
 Appendix J: Fruit and Vegetable Serving Sizes

For the purposes of our analysis, we considered a serving of fruits or vegetables to be one cup.

However, the literature we used to estimate benefits reported servings in grams. We utilized data from the

U.S. Department of Agriculture (USDA) on serving sizes, which included one-cup produce servings with

its gram equivalent, to determine the average grams per cup of fresh fruit and vegetables to be 136

grams.1 This quantity was then used to standardize the serving sizes reported in the literature to estimate

relative risks (RRs) of chronic diseases. For example, the diabetes RR literature reported the decrease in

RR per 106 grams of fruit or vegetable consumed. Consequently, we divided 106 grams by 136 grams to

determine the proportion of one cup of fruit and vegetables associated with a decrease in RR. It is

important to note that the number of grams per cup varies by type of produce, we may be underestimating

benefits of fruit and vegetable consumption. As per data provided by the Rhode Island Public Health

Institute (RIPHI), the existing Food on the Move (FOTM) mobile markets sell fresh produce only.

Therefore, we excluded canned produce, frozen produce, dried fruits, juices, syrups, and other non-fresh

preparations. Detailed average grams per cup of produce are in the following table.2

Table J.1
Average Grams Per Cup of Produce
Item Grams per cup

Apples, peeled, sliced 110

Banana, sliced 150
Blackberries 144
Blueberries 145

Carambola (starfruit), sliced 108

Dates, chopped 178

Grapes 160
Mango, sliced 165
Melon, cantaloupe, cubed 160

1
Gebhardt, S. E. & Thomas, R. G. (2002). Nutritive Value of Foods (Home and Garden Bulletin No. 72). United
States Department of Agriculture, Agricultural Research Service. Retrieved from:
https://www.ars.usda.gov/is/np/NutritiveValueofFoods/NutritiveValueofFoods.pdf.
2
Produce Sold by Site per Day (HQ Top Items Report w CAT).

54
Melon, honeydew, diced 170
Orange sections 180
Papaya, cubed 140
Peaches, sliced 170
Pineapple, diced 155
Plantain, cooked, slices 154
Raspberries 123
Strawberries, sliced 166
Watermelon, diced 152
Alfalfa sprouts, raw 33
Artichokes, globe or French, cooked,
168
drained

Asparagus, cooked, drained, from raw 180

Beans, snap, cut, cooked, drained,

125
green
Bean, snap, cut cooked, drained,
125
yellow
Bean sprouts (mung) 104
Beets 170
Beet greens, leaves and stems, cooked,
144
drained, 1" pieces
Black eyed peas, immature seeds,
165
cooked, drained
Broccoli Raw 88
Cooked, drained from raw 156
Brussels sprouts, cooked, drained,
156
from raw

Cabbage, common varieties, shredded 70

Cabbage, cooked drained 150

Cabbage, pak choi or bok choy 170
Cabbage, pe tsai 119

Cabbage, red, raw, shredded 70

Cabbage, savoy, raw, shredded 70

Grated carrots 110

Carrots, cooked, sliced, drained 156

Cauliflower, raw 100

55
Cauliflower, cooked, drained, 1"
124
pieces
Celery, raw 120
Celery, cooked, drained 150
Collards, cooked, drained, chopped,
190
raw

Corn, from raw, kernels on cob 77

Cucumber, peeled 119

Cucumber, unpeeled 104

Dandelion greens, cooked, drained 105

Eggplant, cooked, drained 99

Endive, curly (including escarole),
50
raw, small pieces

Jerusalem artichoke, raw, sliced 150

Kale, cooked, drained, chopped 130

Kohlrabi, cooked, drained, slices 165

Leeks, bulb and lower leaf portion,

104
chopped or diced, cooked, drained

Lettuce pieces, shredded or chopped 55

Looseleaf lettuce, shredded 56

Lettuce, romaine or cos 56

Mushrooms, raw 70
Mushrooms, cooked 156

Mushrooms, shiitake, cooked 145

Mustard greens, cooked 140

Okra, cooked 160
Onion, raw, chopped 160
Onion, cooked 210
Onions, spring, chopped 100
Parsnips, sliced, cooked 156
Peas, cooked 160

Pepper, green, chopped, raw 149

Pepper, red, chopped, raw 149

Pepper, green, chopped, cooked 136

56
Pepper, red, chopped, cooked 136

Potato, boiled 156

Pumpkin, cooked, mashed 245

Rutabaga, cooked, drained, cubed 170

Soybeans, cooked, drained 180

Spinach, raw, chopped 30

Spinach, cooked 180
Squash, summer, raw 113
Squash, summer, cooked 180

Squash, winter, baked, cubes 205

Tomatoes Raw, year round average 180

Turnips, cooked, cubes. 156

Turnip greens, cooked, drained From
144
raw (leaves and stems)
Average grams/cup 136

57
 Appendix K: Effect of HealthyMatch Consumption on Relative Risk
We based the projected increase in fruit and vegetable consumption on the results of the Healthy

Incentives Pilot (HIP), which reported a 0.24 cup increase in fruit and vegetable intake as a result of the

program.1 For our main analysis, we assumed the effect size of HealthyMatch would be 1.5 times that of

HIP due to the differences in incentive size (dollar-for-dollar match and $0.30 match, respectively).

Serving sizes were standardized by multiplying the projected increase in fruits and vegetables attributable

to HealthyMatch by the number of grams per cup (see Appendix J for further detail on how this number

was calculated). Next, we divided this value by the number of grams per serving size used in the relative

risk (RR) literature to determine the number of servings HealthyMatch will induce participants to

consume. Finally, we multiplied this fraction of a serving by the decrease in RR attributable to

HealthyMatch. The table below contains the grams-to-cups adjustment and the calculated decrease in RR

for all five diseases.

Values used for all risk reduction calculations:

● Additional fruits and vegetables consumed in HealthyMatch: 0.36 cups

● Grams per cup: 136
● Additional grams consumed under HealthyMatch: 0.36·136 = 48.96 g

1
Bartlett, S., & Abt Associates. (2014). Evaluation of the Healthy Incentives Pilot (HIP), Final Report. United
States Department of Agriculture, Food and Nutrition Service, Office of Policy Support.

58
 Table K.1
Calculations of Reduction in Relative Risk Attributable to HealthyMatch

Disease Category

Coronary Heart
Parameter Diabetes Stroke Cancer Depression
Disease (CHD)

RR attributable to 0.89 (midpoint of

a one-serving 0.96 0.96 0.95 uniform 0.97
increase in FV distribution)

Reduction in RR
attributable to a
1-0.96 = 0.04 1-0.96 = 0.04 1-0.95 = 0.05 1-0.89 = 0.11 1-0.97 = 0.03
one-serving
increase in FV

Grams per
serving used in 106 106 106 100 106
relevant literature

Servings
consumed as a 48.96÷100 =
48.96÷106 = 0.46 48.96÷106 = 0.46 48.96÷106 = 0.46 48.96÷106 = 0.46
result of 0.4896
HealthyMatch

Reduction in RR
0.46·0.04 = 0.46·0.04 = 0.4896·0.11 = 0.46·0.03 =
attributable to 0.46·0.05 = 0.023
0.0185 0.0185 0.05386 0.0138
HealthyMatch
1.85 percent 1.85 percent 2.3 percent 5.386 percent 1.38 percent
reduction in RR reduction in RR reduction in RR reduction in RR reduction in RR
due to additional due to additional due to additional due to additional due to additional
Interpretation of
consumption of consumption of consumption of consumption of consumption of
results
0.46 servings 0.46 servings 0.46 servings 0.46 servings 0.46 servings
under under under under under
HealthyMatch HealthyMatch HealthyMatch HealthyMatch HealthyMatch

59
 Appendix L: Direct and Indirect Costs of Coronary Heart Disease

The information presented in this appendix was used in the calculation of benefits associated with

avoided cases of coronary heart disease (CHD). RTI International, a nonprofit research organization,

prepared a report analyzing the projected prevalence and costs of cardiovascular disease in the United

States between 2015 and 2035 for the American Heart Association (AHA).1 The authors used 2010

Census projections of population counts from 2015 to 2035 and national-level data to prepare their

estimates. These include projections for hypertension, CHD, congestive heart failure, stroke, and atrial

fibrillation. The authors found that annual direct costs of CHD are approximately $89 billion and annual

indirect costs approximately $16.1 billion, converted to 2018 dollars.2 Total per person direct and indirect

costs are reported in the table below.

Table L.1
Total and Per Person Annual Costs Attributable to CHD

Total Economic Costs (2017 dollars)

Medical expenditures $89 billion

Reduced productivity $16.1 billion

Per Person Economic Costs (2018 dollars)

Medical expenditures $5,720

Reduced productivity $1,035

Source: Nelson, S., Whitsel, L., Khavjou, O., Phelps, D., & Leib, A. (2016). Projections of Cardiovascular Disease
Prevalence and Costs. American Heart Association. Retrieved from: https://healthmetrics.heart.org/projections-of-
cardiovascular-disease/.
Estimating the Prevalence of CHD
In 2015, 41.5 percent of the United States population experienced at least one cardiovascular

disease (CVD) event. In 2015, 6.8 percent of the population, approximately 16.8 million individuals, had

1
Nelson, S., Whitsel, L., Khavjou, O., Phelps, D., & Leib, A. (2016). Projections of Cardiovascular Disease
Prevalence and Costs. American Heart Association. Retrieved from: https://healthmetrics.heart.org/projections-of-
cardiovascular-disease/.
2
Centers for Disease Control and Prevention (2018). A System for Disseminating Public Health Data and
Information. CDC WONDER. Retrieved from: https://wonder.cdc.gov/.

60
been diagnosed with CHD. Prevalence of CHD increases with age, and is highest among non-Hispanic

white individuals.3

Estimating Costs
The total direct and indirect estimated costs of CHD in 2015 were $187.9 billion: further, $89

billion was attributable to direct medical costs and $98.9 billion was attributable to indirect costs. $16.1

billion of indirect costs were attributed to losses in productivity due to morbidity. Productivity losses

were split into three categories: losses among those currently employed, losses in “home productivity,”

and losses among those who were in too poor of health to work. The authors report annual indirect costs

attributable to CHD morbidity to be $16.1 billion in 2015. Expenditures were calculated as the difference

in medical costs for an individual with CHD relative to an individual without the condition.

To estimate per person costs, we divided reported direct and indirect costs by the number of

individuals reported to be diagnosed with CHD in 2015 (16,835,804), then converted this figure to 2018

dollars. Using this approach, we estimate annual per person direct costs attributable to CHD morbidity to

be approximately $5,720 and indirect costs to be approximately $1,035 in 2018 dollars.

Variation in Estimates
To account for uncertainty in our calculations, we used estimates of direct and indirect costs

attributable to CHD from the 2007 report, “An overview of cardiovascular disease burden in the United

States.”4 We converted the authors’ estimates to 2018 dollars, which equated to $7,265 in direct costs and

$927 in indirect costs. We then subtracted these numbers from the Nelson, et. al estimates and divided the

resulting number by the Nelson, et al. estimate. Using this methodology, we determined 27 percent

uncertainty in direct medical costs and 10 percent variation in indirect costs attributable to CHD.

3
Nelson, S., Whitsel, L., Khavjou, O., Phelps, D., & Leib, A. (2016). Projections of Cardiovascular Disease
Prevalence and Costs. American Heart Association. Retrieved from: https://healthmetrics.heart.org/projections-of-
cardiovascular-disease/.
4
Mensah, G. A., & Brown, D. W. (2007). An overview of cardiovascular disease burden in the United States.
Health Affairs, 26(1), 38-48.

61
 Appendix M: Relative Risk of Coronary Heart Disease
Due to Fruit and Vegetable Consumption

In “Fruit and Vegetable Consumption and Risk of Coronary Heart Disease: A Meta-Analysis of

Cohort Studies,” Dauchet et al. found that each additional portion of fruit and vegetables consumed per

day was associated with a 4 percent decrease in risk of coronary heart disease (CHD).1 We used the

pooled relative risk (RR) of 0.96 identified in this meta-analysis to calculate the expected annual number

of avoided cases of CHD attributable to HealthyMatch.

Methodology
Dauchet et. al conducted a meta-analysis of observational cohort studies examining the

relationship between fruit and vegetable consumption and CHD. Prospective studies published between

1970 and 2006 that provided a quantitative assessment of the relationship between fruit and vegetable

intake and CHD were included. A search of literature yielded nine studies that matched the criteria,

including 221,080 subjects with follow-up between five and 19 years. Included studies contained seven

cohorts from the United States, as well as two from Finland. The authors standardized measurements of

fruit and vegetable servings across studies to present pooled estimates of the RR associated with one-

serving increases in fruit and vegetable consumption (see Appendix J for a detailed explanation of serving

sizes used in our analysis).

Results
Of the nine cohorts included in the meta-analysis, six reported an association between fruit and

vegetable intake and risk of CHD. All six studies observed an inverse relationship with fruit and

vegetable consumption and RR of CHD. Among the six studies, the RR of CHD associated with a one-

serving increase of fruits and vegetables ranged from 0.79 and 0.97. Using a pooled random-effects

model, the authors found the RR of CHD to be 0.96 (95% CI: 0.93–0.99, SE: 0.0153); a one-serving (106

grams) increase in fruits and vegetables was associated with a 4 percent decrease in risk of CHD.

1
Dauchet, L., Amouyel, P., Hercberg, S., & Dallongeville, J. (2006). Fruit and vegetable consumption and risk of
coronary heart disease: a meta-analysis of cohort studies. The Journal of Nutrition, 136(10), 2588-2593.

62
 While the researchers did not control for potential confounders such as lifestyle characteristics

and measurement errors, the results illustrate an association between fruit and vegetable intake and risk of

CHD.

Table M.1
Relative Risk of CHD Associated with Increase in Intake of Fruits, Vegetables, or Fruits and Vegetables

Additional Serving RR of CHD (per 1 serving/day increment)

Fruit only 0.93 (95% CI: 0.89–0.96, SE: 0.01785714)

Vegetables only 0.89 (95% CI: 0.83–0.95, SE: 0.03061224)

Fruit and vegetables 0.96 (95% CI: 0.93–0.99, SE: 0.01530612)

Source: Dauchet, L., Amouyel, P., Hercberg, S., & Dallongeville, J. (2006). Fruit and vegetable consumption and
risk of coronary heart disease: a meta-analysis of cohort studies. The Journal of Nutrition, 136(10), 2588-2593.

63
 Appendix N: Direct and Indirect Costs of Stroke

The information presented in this appendix was used in the calculation of benefits associated with

avoided cases of stroke. RTI International, a nonprofit research organization, prepared a report analyzing

the projected prevalence and costs of cardiovascular disease in the United States between 2015 and 2035

for the American Heart Association.1 This includes projections for hypertension, coronary heart disease

(CHD), congestive heart failure, stroke, and atrial fibrillation. The authors found that direct costs of stroke

are approximately $36.7 billion annually and indirect costs are approximately $6.9 billion.

Table N.1
Total and Per Person Annual Costs Attributable to Stroke

Total Economic Costs (2015 dollars)

Medical expenditures $36.7 billion

Reduced productivity $6.9 billion

Per Person Economic Costs (2018 dollars)

Medical expenditures $5,232

Reduced productivity $984

Source: Nelson, S., Whitsel, L., Khavjou, O., Phelps, D., & Leib, A. (2016). Projections of Cardiovascular Disease
Prevalence and Costs. American Heart Association. Retrieved from: https://healthmetrics.heart.org/projections-of-
cardiovascular-disease/.

Prevalence of Stroke
In 2015, 3 percent of the population (approximately 7.5 million individuals) experienced a stroke.

The authors projected that by 2035 the prevalence of stroke will rise to 3.8 percent, or approximately 11.2

million individuals. Prevalence of stroke increases with age, and is more common among females than

males.

1
Nelson, S., Whitsel, L., Khavjou, O., Phelps, D., & Leib, A. (2016). Projections of Cardiovascular Disease
Prevalence and Costs. American Heart Association. Retrieved from: https://healthmetrics.heart.org/projections-of-
cardiovascular-disease/.

64
Direct and Indirect Costs of Stroke
The total direct and indirect estimated costs of stroke in 2015 were $66.3 billion: further, $36.7

billion was attributable to direct medical costs and $29.6 billion was attributable to indirect costs. $6.9

billion of indirect costs were attributed to morbidity. The authors used Medical Expenditure Panel Survey

(MEPS) data to estimate participant utilization of medical services and the associated costs. Costs were

estimated by the following point-of-service categories: hospital (inpatient, outpatient, emergency room),

physician (office-based visits), prescription (prescription), home health (home health), and other (vision,

medical supplies, dental). Expenditures were calculated as the difference in medical costs for an

individual with stroke relative to one without the condition.

The authors calculated total indirect costs as those attributable to both morbidity and mortality.

For the purposes of this analysis, we only include costs attributable to morbidity. Morbidity costs entail

earnings as a result of decreased productivity attributable to stroke. Productivity losses were split into

three categories: losses among those currently employed, losses in “home productivity,” and losses

among those who were in too poor of health to work. The authors report annual indirect costs attributable

to stroke morbidity to be $6.9 billion in 2015.

We divided reported direct and indirect costs by the number of individuals reported to be

diagnosed with stroke in 2015 (7,483,839) to estimate annual per person costs attributable to stroke and

then inflated this figure to 2018 dollars. Using this approach, we estimate annual per person direct costs

attributable to stroke morbidity to be approximately $5,232 and indirect costs to be approximately $984

in 2018 dollars.

Variation in Estimates
To account for uncertainty in our estimates, we used estimates of direct and indirect costs

attributable to stroke from the 2007 report “An overview of cardiovascular disease burden in the United

States” by George A. Mensah and David W. Brown.2 We inflated these estimates to 2018 dollars, which

2
Mensah, G. A., & Brown, D. W. (2007). An overview of cardiovascular disease burden in the United States.
Health Affairs, 26(1), 38-48.

65
equated to $8,507 in direct costs and $1,461 in indirect costs. We then subtracted these numbers from the

Nelson, et. al estimates and divided the resulting number by the Nelson, et al. estimate. Using this

methodology, we determined 63 percent variation in direct medical costs and 49 percent variation in

indirect costs attributable to stroke. While we acknowledge the high level of uncertainty in these

estimates, we ascribe said uncertainty to the varying levels of severity of stroke.

Table N.2
Direct and Indirect Costs (In Billions of Dollars) of Cardiovascular Disease and Stroke, 2006

Source: Mensah, G. A., & Brown, D. W. (2007). An overview of cardiovascular disease burden in the United
States. Health Affairs, 26(1), 38-48.

66
 Appendix O: Relative Risk of Stroke due to Fruit and Vegetable Consumption

In “Fruit and Vegetable Consumption and Risk of Stroke A Meta-Analysis of Cohort Studies,”

Dauchet et al. found that each additional portion of fruit and vegetables consumed per day was associated

with a relative risk (RR) of 0.95, or a 5 percent decrease in the risk of stroke.1 We used this RR to

calculate the expected annual number of avoided cases of stroke attributable to HealthyMatch.

Methodology
The authors conducted a meta-analysis of cohort studies to examine the relationship between fruit

and vegetable consumption and risk of stroke. Studies that relied upon a validated questionnaire for food

intake assessment and reported RRs for any type of stroke were included in the meta-analysis. Dauchet et

al. identified seven studies that were eligible for inclusion, resulting in a subject pool of 90,513 men,

141,536 women and 2,955 strokes. The average length of follow-up time for these studies was 10.7 years.

The authors standardized measurements of fruit and vegetable servings across studies to present pooled

estimates of the RR associated with one-serving increases in fruit and vegetable consumption (see

Appendix J for a detailed explanation of the serving sizes used in our analysis).

Results
Six of the seven studies reported an association between fruit and vegetable consumption and

stroke. The RRs of stroke for each increment of one serving (106 grams) of fruits and vegetables per day

ranged from 0.91 to 0.96. In a fixed effect model, the pooled RR for both ischemic and hemorrhagic

strokes was 0.95 (95% CI: 0.92–0.97). The authors found a linear association between fruit and vegetable

intake and decreased occurrence of stroke, suggesting the existence of a dose-response relationship. This

meta-analysis was limited in that the included studies did not employ randomized controlled trials, which

the authors argue are not feasible in this line of research.

1
Dauchet, L., Amouyel, P., & Dallongeville, J. (2005). Fruit and vegetable consumption and risk of stroke: a meta-
analysis of cohort studies. Neurology, 65(8), 1193-1197.

67
Table O.1
Relative Risk of Stroke Associated with Increase in Intake of Fruits, Vegetables, or Fruits and Vegetables

Additional Serving RR of stroke (per 1 serving/day increment)

Fruit only 0.89 (95% CI: 0.85–0.93, SE: 0.020408163)

Vegetables only 0.97 (95% CI: 0.92–1.02, SE: 0.025510304)

Fruit and vegetables 0.95 (95% CI: 0.92–0.97, SE: 0.015306122, 0.010204082)

Source: Dauchet, L., Amouyel, P., & Dallongeville, J. (2005). Fruit and vegetable consumption and risk of stroke: a
meta-analysis of cohort studies. Neurology, 65(8), 1193-1197.

68
 Appendix P: Direct and Indirect Costs of Diabetes

The information presented in this appendix was used in the calculation of benefits associated with

avoided cases of diabetes. Combining 2017 U.S. population demographics with diabetes prevalence data,

health care cost data, and economic data, the American Diabetes Association (ADA) analyzed the

nationwide economic burden of diabetes, including both healthcare resource use and lost productivity.1

They utilized both state- and national-level data for estimates, in order to reflect variation across states in

demographics, health risk factors, lifestyle choices, prices, and economic outcomes.

The authors determined that the total estimated cost of diagnosed diabetes in the U.S. in 2017 was

$327 billion, including $237 billion in direct medical costs and $90 billion in reduced productivity

(including reduced productivity due to mortality). Health care cost data included total health care

expenditures for people with diabetes relative to the projected level of expenditures that they would have

incurred in the absence of diabetes. Resulting per person health care costs are reported below.

Table P.1
Total and Per Person Annual Costs Attributable to Diabetes

Total Economic Costs (2017 dollars)

Medical expenditures $237 billion

Reduced productivity $70 billion

Per Person Economic Costs (2018 dollars)

Medical expenditures $9,877 (% uncertainty: 24.33)

Reduced productivity $2,915 (% uncertainty: 24.33)

Source: American Diabetes Association. (2018). Economic Costs of Diabetes in the US in 2017. Diabetes Care,
41(5), 917-928.

Estimating Size of the Population with Diabetes

The ADA estimated that as of 2017, 24.7 million people in the U.S. have diabetes, or

approximately 7.6 percent of the total population (and 9.7 percent of the adult population). To reach this

1
American Diabetes Association. (2018). Economic Costs of Diabetes in the US in 2017. Diabetes Care, 41(5),
917-928.

69
number, it estimated the prevalence of diagnosed diabetes for 480 population strata controlling for state,

age group, sex, race/ethnicity, insurance status, and whether residing in the community, a residential care

facility, or a nursing home.

Estimating Costs
People with diagnosed diabetes incur medical expenditures of approximately $16,750 per year,

approximately $9,600 of which is attributed to diabetes. Diabetes requires spending on direct treatment

and maintenance as well as increasing the costs of treating conditions not directly related to the disease.

The full model includes diabetes status as the main explanatory variable, as well as predictors of health

service utilization as covariates, including age, sex, education level, income, marital status, medical

insurance status, and race/ethnicity. It also omits highly related conditions or complications of diabetes,

such as hypertension, as including such variables could downward bias the estimated relationship between

diabetes and health care use.

Assumptions and Adjustments

The ADA cost study does not differentiate between Type 1 and Type 2 diabetes. Type 2 diabetes

is determined primarily by both lifestyle and genes, and thus its likelihood is significantly affected by

obesity status. Type 1 diabetes is inherited genetically and does not develop due to diet or lifestyle

habits.2 Consequently, fruit and vegetable consumption might not have an effect on the incidence of Type

1 diabetes. However, approximately 5 percent of all diabetes cases are Type 1.3 As this is a small

percentage of the total population diagnosed with diabetes, we utilized the ADA cost data regardless of its

inclusion of Type 1 diabetes costs.

We also adjusted indirect/productivity cost data to remove the costs of mortality. To extract

mortality costs from total indirect costs, we subtracted costs due to mortality ($19.9 billion) from the total

indirect costs of diabetes ($89.9 billion), resulting in $70 billion in total morbidity-related losses due to

2
Risérus, U., Willett, W. C., & Hu, F. B. (2009). Dietary fats and prevention of type 2 diabetes. Progress in Lipid
Research, 48(1), 44-51.
3
Centers for Disease Control and Prevention (2018). Type 1 diabetes. Retrieved from:
https://www.cdc.gov/diabetes/basics/type1.html.

70
diabetes.4 We then divided these total productivity losses by the number of people with diabetes (24.7

million), resulting in a per person productivity cost of $2,834.

Research on diabetes costs is quite limited and the ADA estimates were by far the most robust. A

meta-analysis of other studies on annual per capita costs of diabetes worldwide found extensive variation

in U.S. estimates of diabetes costs, clustering between approximately $4,000 and approximately $11,000

in 2011 dollar values.5 Converted into 2017 dollar values, the same as the ADA’s estimates, the ceiling of

this range is $11,937. We then calculated uncertainty using the ADA’s point estimate of $9,601and an

upper cost limit of $11,937, leaving a range of $2,336 above and below the ADA estimate, or 24.33

percent uncertainty.

Table P.2
Detailed Cost Components - Total Health Care Expenditures

Source: American Diabetes Association. (2018). Economic Costs of Diabetes in the US in 2017. Diabetes Care,
41(5), 917-928.

4
Ibid.
5
Ibid.

71
Table P.3
Detailed Cost Components - Lost Productivity

Source: Ibid.

72
 Appendix Q: Relative Risk of Diabetes due to Fruit and Vegetable Consumption

Li et al. conducted a meta-analysis of studies examining the potential association between fruit

and vegetable consumption and risk of Type 2 diabetes.1 They concluded that higher fruit and green leafy

vegetable consumption is associated with a significantly reduced risk of Type 2 diabetes. The association

between fruit and vegetable consumption and relative risk (RR) of diabetes does not significantly differ

by sex, body mass index (BMI), or smoking status, though having a BMI greater than 25 is a major risk

factor for diabetes.2,3 We used the pooled RR of 0.96 identified in this meta-analysis to calculate the

expected annual number of avoided cases of diabetes attributable to HealthyMatch.

Methodology
The meta-analysis incorporates findings from ten prospective cohort studies, which include

24,013 cases of Type 2 diabetes and 434,342 participants. The authors computed pooled RRs of disease

based on fruit and vegetable consumption. For the dose-response analyses, the authors standardized

serving sizes across studies at 106 grams per serving (see Appendix J for a detailed explanation of serving

sizes used in our analysis).4

Results
Dose-response analysis of fruit intake indicated that each additional serving (106 grams) per day

of fruit lowers risk of diabetes by 6 percent. Dose-response analysis of vegetable intake indicated no

association between additional daily servings of vegetables and Type 2 diabetes risk, nor did dose-

response analysis of combined fruit and vegetable intake indicate an association between additional daily

servings and Type 2 diabetes risk.5 Although the researchers obtained a RR below 1, the confidence

intervals (CIs) for both fruit and vegetable intake and vegetable intake have an upper limit greater than 1,

1
Li, M., Fan, Y., Zhang, X., Hou, W., & Tang, Z. (2014). Fruit and vegetable intake and risk of type 2 diabetes
mellitus: meta-analysis of prospective cohort studies. BMJ Open, 4(11), 1-9.
2
Cooper, A. J., et al. (2012). Fruit and vegetable intake and type 2 diabetes: EPIC-InterAct prospective study and
meta-analysis. European Journal of Clinical Nutrition, 66(10), 1394-1408.
3
Liu, S., et al. (2004). A prospective study of fruit and vegetable intake and the risk of type 2 diabetes in women.
Diabetes Care, 27(12), 2993-2996.
4
Ibid.
5
Ibid.

73
meaning that the researchers did not find a conclusive relationship between increased intake and lower

RR of diabetes. Finally, dose-response analysis of green leafy vegetable intake indicated that an

additional 0.2 servings per day was associated with a 13 percent lower risk of Type 2 diabetes.6 No

publication bias was observed. Standard errors were calculated by subtracting the lower bound of the CI

from the upper bound and then dividing by 3.92.

Table Q.1
Relative Risk of Diabetes Associated with Increase in Intake of Fruits, Vegetables, or Fruits and Vegetables

Additional Serving RR of Diabetes (per 1 serving/day increment)

Fruit only 0.94 (95% CI: 0.89-1.00, SE: 0.02806122)

Vegetables only 0.98 (95% CI: 0.89-1.08, SE: 0.04846939)

Fruit and vegetables 0.96 (95% CI: 0.86-1.07, SE: 0.05357143)

Green leafy vegetables 0.87 (95% CI: 0.76-0.99, SE: 0.05867347)

Source: Liu, S., et al. (2004). A prospective study of fruit and vegetable intake and the risk of type 2 diabetes in
women. Diabetes Care, 27(12), 2993.

6
Ibid.

74
 Appendix R: Direct and Indirect Costs of Cancer

The information presented in this appendix was used in the calculation of benefits associated with

avoided cases of cancer. The study by Short et al. (2010) was selected for our analysis as it provides

national estimates of medical expenditures for cancer survivors.1 The term “cancer survivor,” as defined

by the National Cancer Institute, refers to an individual from the “time of their diagnosis through the

balance of his or her life...this definition implies that the population of survivors includes all living

individuals ever diagnosed with cancer and corresponds exactly to the epidemiologic concept of

prevalence.” The authors focused on medical expenditures of adult cancer survivors ages 25 to 64 years,

as medical care is often financed differently prior to age 65. Due to large cost differences between those

with new cancer diagnoses and those who were previously diagnosed, the authors separated costs based

on diagnosis type. Mean total expenditures for each diagnosis type are as follows:

Table R.1
Mean Medical Expenditures for Adults with Cancer (Ages 25 to 64 years), 2007

Cancer Survivor
No Cancer
Newly Diagnosed Previously Diagnosed

Population (millions) 1.0 5.5 147.0

Mean total expenditures $16,910 $7,992 $3,303

Source: Short, Pamela Farley, Moran, John R., & Punekar, Rajeshwari (2010). Medical expenditures of adult cancer
survivors aged <65 years in the United States. Cancer, 117(12),
2791-2800.

Establishing a Representative Sample

Using two nationally representative surveys, the Household Component of the MEPS (MEPS-

HC) and the National Health Institute Survey (NHIS), authors used classification codes to identify

individuals with cancer. Annual data from both surveys, between 2001 through 2007, was pooled to

1
Short, Pamela Farley, Moran, John R., & Punekar, Rajeshwari (2010). Medical expenditures of adult cancer
survivors aged <65 years in the United States. Cancer, 117(12), 2791-2800.

75
obtain a “large enough sample of cancer survivors to make reliable estimates for survivor subgroups and

to characterize entire expenditure distributions for survivors.”2

Estimating Costs
The authors found that “the mean annual expenditure on all services for individuals with newly

diagnosed cancer in 2007 was $16,910 ± $3911. The mean was approximately half as large for survivors

who were diagnosed in previous years ($7992 ± $972), but it was more than twice that for adults who had

no history of cancer ($3303 ± $103). Although new diagnoses accounted for only 15 percent of the total

number of cancer survivors, they accounted for 28 percent of total survivor spending.”3 For the purposes

of this analysis, only newly diagnosed cases of cancer and associated costs were used, as the

HealthyMatch program aims to reduce new cases of chronic disease in the long run through increased

consumption of fruits and vegetables.

Costs related to cancer are also seen in terms of absenteeism or lost work days. Below is an

explanation of the avoided work days lost due to cancer. Costs were converted from monthly costs

(reported below) to annual costs for the purposes of the analysis.

Chang et al. (2004) measured indirect costs by days absent from work and short-term disability

days used per month. The study population was drawn from MarketScan 1998 to 2000 Commercial

Claims and Encounters, Medicare Supplemental and Coordination of Benefits, and Health and

Productivity Management databases.4 This represents approximately 3 million employees, dependents,

and retirees in the U.S. Authors used a retrospective matched cohort study to compare newly diagnosed

patients to a control group without cancer. Days absent from work and short-term disability (STD) days

use per month were used to determine indirect costs.

Results indicated that employees with cancer had taken more mean monthly STD days than

controls (5.2 v 0.2 days; p < .05), translating to mean monthly costs of absenteeism of $373 ($4,476 per

2
Ibid.
3
Ibid.
4
Chang, Stella, Long, Stacey R., Kutikova, Lucie, Bowman, Lee, Finley, Denise, Crown, William H., & Bennett,
Charles L. (2004). Estimating the cost of cancer: Results on the basis of claims data analyses for cancer patients
diagnosed with seven types of cancer during 1999 to 2000. Journal of Clinical Oncology, 22(17), 3524-3530.

76
year) and STD days of $698 ($8,376 per year) among cancer patients (p < .05).5 Thus, the total annual per

person costs of cancer are estimated to be $29,762.

Table R.2
Monthly Indirect Costs Attributable to Cancer

NUMBER OF STANDARD
MEAN
PATIENTS DEVIATION

Absenteeism

Cancer 127 $373 $709

Controls 426 $101 $335

Incremental Cost $272 $440

Short-Term Disability

Cancer 349 $698 $1,242

Controls 1,180 $25 $220

Incremental Cost $673 $623

Source: Chang, Stella, Long, Stacey R., Kutikova, Lucie, Bowman, Lee, Finley, Denise, Crown, William H., &
Bennett, Charles L. (2004). Estimating the cost of cancer: Results on the basis of claims data analyses for cancer
patients diagnosed with seven types of cancer during 1999 to 2000. Journal of Clinical Oncology, 22(17), 3524-
3530.

5
Ibid.

77
 Appendix S: Relative Risk of Cancer due to Fruit and Vegetable Consumption

A study by Riboli and Norat (2003) found that a significant reduction in the risk of various types

of cancer is associated with fruit and vegetable consumption.1 We operated under the assumption that the

authors refer to the reduction is risk of cancer as a reduction in new cancer diagnoses. We used the

relative risk (RR) identified in this meta-analysis to calculate the expected annual number of avoided

cases of cancer attributable to HealthyMatch.

The academic literature surrounding cancer separates the RR of cancer by cancer type. Abundant

literature exists evaluating RR and the protective effects fruit and vegetable consumption. However,

rather than reporting the RR of increased fruit and vegetable consumption for all cancers, researchers

report results by varying types of cancer. Riboli and Norat (2003) used a meta-analysis to examine case-

control and cohort studies that reported on total fruit and vegetable intake and cancer risk. Prospective

studies published between January 1973 and June 2001 and referenced in the MEDLINE database were

included. “Individual slopes of each study were combined, weighting by the inverse of their variances.

Random effect models were assumed when there was evidence of heterogeneity.”2 Among the considered

cancer types, the RR of cancer was associated with a one-serving increase of fruits and vegetables ranged

from 0.805 to 0.975 (see Appendix J for a detailed explanation of serving sizes used in our analysis). We

used these estimates to create an interval for a uniform distribution.

1
Riboli, Elio & Norat, Teresa (2003). Epidemiologic evidence of the protective effect of fruit and vegetables on
cancer risk. The American Journal of Clinical Nutrition, 78(3), 559S-569S.
2
Ibid.

78
Table S.1
Relative Risk of Cancer Associated with Increase in Intake of Fruits and Vegetables, by Cancer Type

Cancer Type Point Estimate Standard Deviation

Esophageal 0.805 (0.67, 0.97)

Gastric 0.815 (0.635, 1.04)

Colorectal 0.95 (0.865, 1.03)

Breast 0.975 (0.96, 0.99)

Lung 0.835 (0.80, 0.955)

*Relative risk was indicated for each cancer type for both fruit and vegetables. Point estimates for each cancer type
were calculated by taking the average of the fruit and vegetable relative risks.
*Information was compiled from the studies’ Tables 2, 3 and 4.
*95% CI
Source: Riboli, Elio & Norat, Teresa (2003). Epidemiologic evidence of the protective effect of fruit and vegetables
on cancer risk. The American Journal of Clinical Nutrition, 78(3), 559S-569S.

Results indicate that for both case-control and cohort studies, fruit and vegetable consumption

yield a protective effect for the cancer diagnoses considered. It is important to note that researchers found

for some cancer types, fruits have a more significant protective effect, while for others, vegetables have a

more significant protective effect. It is also important to acknowledge that the serving sizes used in Riboli

& Norat (2003) are smaller than those used in the literature regarding RRs of other diseases such as

coronary heart disease (CHD), diabetes, and stroke (see Appendix I). Smaller serving sizes indicate that

participants did not consume high levels fruits and vegetables. It is possible that as the RR of cancer

based on fruit and vegetable consumption is not as high as it is for other diseases, we calculated fewer

avoided cases and thus understated benefits.

79
 Appendix T: Direct and Indirect Costs of Depression

The information presented in this appendix was used in the calculation of benefits associated with

avoided cases of depression. Using national survey and administrative claims data, Greenberg et al.

(2015) estimated the incremental economic burden on adults with major depressive disorder (MDD) in

the United States.1 Data was collected from the Optum Health Reporting and Insights administrative

claims database, which includes over 16 million beneficiaries from 69 large U.S. companies. Using direct

characteristic matching and propensity score analysis, the researchers were able to determine likely

comorbidities and control for these comorbidities in their health care cost determinations.

In 2010, people with depression incurred medical expenditures of approximately $10,379 per

year, approximately $5,988 of which was directly attributable to MDD (these estimates are reported in

2012 dollars). Although the researchers did not separate indirect costs into costs directly attributable to

depression and costs attributable to its comorbid diseases, they did note that 38 percent of total costs were

directly attributable to depression itself, as opposed to its comorbid conditions. Consequently, we

multiplied the per person indirect costs of MDD of $4,084 by 0.38 to determine total indirect medical

costs directly attributable to MDD of $1,551.92. These indirect productivity costs include both

presenteeism and absenteeism. In 2018 dollars, per person medical costs and indirect costs are $6,575.40

and $1,704.16 respectively.

To obtain standard errors (SEs), we utilized a study by Egede et al. (2016) that examined the

incremental medical costs of depression amongst individuals with diabetes.2 They found that symptomatic

depression increased medical costs by $4,977.71 (converted from 2014 to 2012 dollars) compared to

patients with no depression. Using $4,977.71 as a lower bound, we applied a confidence interval (CI) of

1
Greenberg, P. E., Fournier, A. A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The economic burden of adults
with major depressive disorder in the United States (2005 and 2010). The Journal of Clinical Psychiatry, 76(2), 155-
162.
2
Egede, L. E., Walker, R. J., Bishu, K., & Dismuke, C. E. (2016). Trends in costs of depression in adults with
diabetes in the United States: Medical Expenditure Panel Survey, 2004–2011. Journal of General Internal Medicine,
31(6), 615-622.

80
$4,977.71-$5,362.29, or a percent uncertainty of 3.72 percent, to both medical cost estimates and

productivity cost estimates.

Table T.1
Total and Per Person Annual Costs Attributable to Depression

Total Economic Costs (2012 dollars)

Medical expenditures $98.9 billion

Reduced productivity $39 billion

Per Person Economic Costs (2018 dollars)

Medical expenditures $6,575.40 (% uncertainty: 3.72)

Reduced productivity $1,704.16 (% uncertainty: 3.72)

Source: Greenberg, P. E., Fournier, A. A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The economic burden
of adults with major depressive disorder in the United States (2005 and 2010). The Journal of Clinical Psychiatry,
76(2), 155-162.

81
 Appendix U: Relative Risk of Depression due to Fruit and Vegetable Consumption

In a meta-analysis of the association between fruit and vegetable intake and depression, Saghafian

et al. found that increased fruit and vegetable consumption may reduce risk of depression.1 We used the

relative risk (RR) identified in this meta-analysis to estimate the expected annual number of avoided cases

of depression attributable to HealthyMatch.

Methodology

The meta-analysis included 27 fruit, vegetable, or fruit and vegetable intake studies, including 10

from European countries, five from the Americas, eight from Asia, and four from Australia. In total, the

studies included 289,018 participants. Most of the studies were cohort studies comparing highest and

lowest intake levels of fruits and/or vegetables. To determine a dose-response effect of fruit and vegetable

consumption, the authors utilized the natural logs of RR and confidence intervals (CIs) across cohorts of

fruit and vegetable intake to compute study-specific slopes.

Results

The dose-response analysis indicated that every 100-gram increase in fruit intake was associated

with a three percent reduced risk of depression, or a RR of 0.97 (95% CI: 0.95-0.99). Every 100-gram

increase in vegetable intake was associated with a three percent reduced risk of depression, or a relative

risk of 0.97 (95% CI: 0.95-0.98). We utilized the wider confidence interval, 0.95-0.99, for a more

conservative estimate of the effects of an increase fruit and vegetable consumption on depression. As

noted in Appendix J, we found that one cup of fruits and vegetables is approximately 136 grams.

Consuming 136 grams of fruit or vegetables will have a greater effect on RR than consuming 100 grams.

By dividing 100 grams by 136 grams, we converted the serving size in grams used in this study to cups to

determine that consuming 0.7335 additional cups of fruit or vegetables reduces RR of depression by 3

percent, or a RR of 0.97 (95% CI: 0.95-0.99). Standard errors (SEs) were calculated by subtracting the

lower bound of the CI from the upper bound and then dividing by 3.92.

1
Saghafian, F., Malmir, H., Saneei, P., Milajerdi, A., Larijani, B., & Esmaillzadeh, A. (2018). Fruit and vegetable
consumption and risk of depression: accumulative evidence from an updated systematic review and meta-analysis of
epidemiological studies. British Journal of Nutrition, 119(10), 1087-1101.

82
Table U.1
Relative Risk of Depression Associated with Increase in Intake of Fruits, Vegetables, or Fruits and Vegetables

Additional Serving RR of Depression (per 100g/day increment)

Fruit only 0.97 (95% CI: 0.95–0.99, SE: 0.01020408)

Vegetables only 0.97 (95% CI: 0.95–0.98, SE: 0.00765306)

Fruit and vegetables

0.97 (95% CI: 0.95–0.99, SE: 0.01020408)
(assumed)

Source: Saghafian, F., Malmir, H., Saneei, P., Milajerdi, A., Larijani, B., & Esmaillzadeh, A. (2018). Fruit and
vegetable consumption and risk of depression: accumulative evidence from an updated systematic review and meta-
analysis of epidemiological studies. British Journal of Nutrition, 119(10), 1087-1101.

83
 Appendix V: Income Transfer From HealthyMatch

Our model interprets the HealthyMatch benefits provided as an income transfer, where the

subsidy creates a higher level of expendable income for the SNAP beneficiary. As shown in Figure V.1,

the transfer only impacts the inframarginal consumption of fruits and vegetables, or the proportion of

consumption that would occur regardless of participation in HealthyMatch. The income transfer

effectively offsets the inframarginal portion of government expenditures--that is, the fraction of

expenditures situated below the margin--on the provision of HealthyMatch benefits, as participants are

spending a reduced amount on their original level of fruit and vegetable consumption. As the original

level of consumption is subsidized through the provision of HealthyMatch benefits, the subsidized portion

of these purchases is effectively translated into expendable income for the beneficiary. The remaining

portion of government expenditures is not considered a transfer, as the observed increase in consumption

is induced by participation in the program. The shaded triangle in Figure V.1 is counted as an additional

benefit category captured as consumer surplus from additional fruit and vegetable consumption (see

Appendix W for more details).

Figure V.1
HealthyMatch Consumer Impact – Income Transfer

84
 Appendix W: Consumer Surplus from HealthyMatch

Our analysis includes the direct consumer surplus from increased fruit and vegetable consumption

as a benefit, indicated by the shaded triangle in Figure W.1. We assume participants of HealthyMatch do

not fully anticipate the accrual of health benefits resulting from increased consumption of fruits and

vegetables. Consequently, the resulting consumer surplus induced by the Healthy Match incentive is

considered an internality, or a benefit not considered by individuals when consuming a good.

While one may claim that benefits of the shaded triangle of consumer surplus are captured in the

monetizing of health benefits, we assume a demand schedule that is not fully informed. We assume that

HealthyMatch participants would not be fully informed about the benefits of fruit and vegetable

consumption, and that demand would likely increase given perfect information and income flexibility.

The red line on Figure W.1 represents this potential demand schedule. The trapezoid above the new price

following implementation of HealthyMatch (P1) and below the informed (red) demand curve represents

the fully informed measure of social surplus. The shaded triangle represents direct consumer surplus. The

remaining parallelogram represents consumer surplus in the form of unanticipated future health benefits

that are not taken into account in the uninformed demand schedule.

Figure W.1
HealthyMatch Consumer Impact – Consumer Surplus

85
 Appendix X: Reduction in Transportation Costs

We did not account for the potential benefits HealthyMatch program participants might accrue

through reduced transportation costs of traveling to grocery stores. These costs could include gasoline,

bus fare, time costs of a longer walk, etc. People who live in food deserts, or areas lacking fresh fruits,

vegetables, and other healthy whole foods, often incur higher transportation and time costs to access

healthy foods because they live further from grocery stores.1,2 Although there is a lack of consensus on

the definition of a food desert, it is generally believed to be associated with neighborhoods facing

segregation, poverty, and deprivation.3,4 By incentivizing the purchase of fresh fruits and vegetables at

stores that are more accessible to low-income individuals, HealthyMatch could potentially lower

transportation costs and result in an additional benefit to its participants. However, we were unable to

monetize this benefit due to lack of data on travel times to grocery stores and costs of travel.

Because low-income neighborhoods have fewer and smaller retail establishments, residents must

travel more than two additional miles to access the same number of supermarkets as residents of non-poor

neighborhoods.5 These small retail establishments also tend to charge more for produce than the large

grocery stores more common in non-poor neighborhoods, meaning that residents of poor neighborhoods

face higher fruit and vegetable prices.6 Even among chain supermarkets, healthy foods are less available

in neighborhoods with lower median household income. Residents of poor neighborhoods are also less

likely to own cars, meaning that they add to travel time by relying on public transportation or walking.7

1
Gallagher, M. (2018). USDA Defines Food Deserts. Nutrition Digest. Retrieved from:
http://americannutritionassociation.org/newsletter/usda-defines-food-deserts.
2
Anekwe, T. D., & Rahkovsky, I. (2013). Economic costs and benefits of healthy eating. Current Obesity Reports,
2(3), 225-234.
3
Hendrickson, D., Smith, C., Eikenberry, N., 2006. Fruit and vegetable access in four low-income food deserts
communities in Minnesota. Agriculture and Human Values, 23(3), 371–383.
4
Gee, G.C., Payne-Sturges, D.C., 2004. Environmental health disparities: a framework integrating psychosocial and
environmental concepts. Environmental Health Perspectives, 112(17), 1645–1653.
5
Alwitt, L.F., Donley, T.D., 1997. Retail Stores in Poor Urban Neighborhoods. The Journal of Consumer Affairs
31(1), 139–164.
6
Chung, C., & Myers Jr, S. L. (1999). Do the poor pay more for food? An analysis of grocery store availability and
food price disparities. Journal of Consumer Affairs, 33(2), 276-296.
7
Krukowski, R. A., West, D. S., Harvey-Berino, J., & Prewitt, T. E. (2010). Neighborhood impact on healthy food
availability and pricing in food stores. Journal of Community Health, 35(3), 315-320.

86
 One qualitative study using focus groups composed of SNAP recipients revealed that many

SNAP recipients see transportation as a major obstacle to accessing fruits and vegetables. Transportation

was especially a concern for participants who did not own cars.8 Another study found that residents in

many of the Philadelphia neighborhoods lacking access to large supermarkets faced greater likelihood of

health challenges including diabetes, heart disease, and cancer.9 In sum, residents of low-income

neighborhoods are more likely to face transportation challenges that incur additional time costs upon fruit

and vegetable consumption, or prevent them from obtaining fruits and vegetables because of high

transportation and time costs.

8
Haynes-Maslow, L., Auvergne, L., Mark, B., Ammerman, A., & Weiner, B. J. (2015). Low-income individuals’
perceptions about fruit and vegetable access programs: a qualitative study. Journal of Nutrition Education and
Behavior, 47(4), 317-324.
9
Cotterill, R. W., & Franklin, A. W. (1995). The Urban Grocery Store Gap (No. 08). University of Connecticut,
Department of Agricultural and Resource Economics, Charles J. Zwick Center for Food and Resource Policy.
Retrieved from: https://ideas.repec.org/p/zwi/ipaper/08.html.

87
 Appendix Y: Externalities Associated with Poverty

We did not account for the potential external social benefits that HealthyMatch might induce as a

result of an income transfer to its participants. As the program offers a dollar-for-dollar match on fresh

produce purchased at participating retailers, participants would realize a “gain” in income that would have

otherwise been spent on full price fruits and vegetables. According to Haveman and Wolfe (1984), an

income gain among low-income individuals reduces the incidence of poverty, which in turn provides a

benefit to society in the form of reduced negative externalities, such as reduced crime. The authors use

additional years of schooling as a determinant of increased income, as earnings typically rise in tandem

with an individual’s level of education. Haveman and Wolfe argue that the standard estimates of the

economic value of additional schooling do not take into account the aforementioned positive externalities

associated with a decrease in poverty.1 We assume that the income transfer produced by HealthyMatch

would result in societal benefits similar to those modeled by Haveman and Wolfe; however, we were

unable to monetize those benefits in our analysis.

1
Haveman, R., & Wolfe, B. (1984). Schooling and Economic Well-Being: The Role of Nonmarket Effects. The
Journal of Human Resources, 19(3), 377-407.

88
 Appendix Z: Food Insecurity and Educational Outcomes in Children and Adolescents

Though the literature suggests that both heightened food security and improved diet have a

positive effect on the educational outcomes of children and adolescents, our team was unable to monetize

the long-term economic outcomes of children whose fruit and vegetable consumption would likely

increase with the HealthyMatch incentive program. Generally, the research shows that the receipt of

SNAP benefits reduces the incidence of grade repetition and increases the likelihood of grade retention

and graduation among low-income students from economically strained households.1,2 In a study

conducted by Alaimo et al. (2001), researchers used data from the Third National Health and Nutrition

Examination Survey (NHANES III) to determine the degree to which a cohort of children were food-

insufficient (an analogous term for food insecurity). The results showed that food-insufficient children

had significantly lower scores on arithmetic and reading tests and were more likely to be absent or

suspended from school than their food-sufficient peers. Food insufficiency also predicted various

psychosocial outcomes, such as difficulty making friends.3 The table below illustrates the differences

between food-sufficient and insufficient children in this study.

1
Gassman-Pines, A., & Bellows, L. (2018). Food Instability and Academic Achievement: A Quasi-Experiment
Using SNAP Benefit Timing. American Educational Research Journal, 55(5), 897–927.
2
Hickson, M., Ettinger de Cuba, S., Weiss, I., Donofrio, G., & Cook, J. (2013). Feeding Our Human Capital: Food
Insecurity and Tomorrow’s Workforce (Issue brief). Retrieved from: http://www.childrenshealthwatch.org/wp-
content/uploads/FeedingHumanCapital_report.pdf.
3
Alaimo, K., Olson, C. M., & Frongillo, E. A., Jr. (2001). Food insufficiency and American school-aged children’s
cognitive, academic, and psychosocial development. Pediatrics, 108(1), 44-53.

89
Table Z.1
Cognitive, Academic, and Psychosocial Outcomes by Food Sufficiency Status for Children and Teenagers

Source: Alaimo, K., Olson, C. M., & Frongillo, E. A., Jr. (2001). Food insufficiency and American school-aged
children’s cognitive, academic, and psychosocial development. Pediatrics, 108(1), 44-53.

There is further evidence to suggest that improved diet may result in better academic and health

outcomes, particularly among low-income students. The School Breakfast Program (SBP), administered

by the U.S. Department of Agriculture (USDA), provides free or reduced price breakfast to students

whose families are at or below 130 and 185 percent of the federal poverty line, respectively. The meals

must meet the USDA’s Dietary Guidelines for Americans, including required servings of fruits and/or

vegetables.4,5 Research shows that participation in SBP or similar programs is positively associated with

improved math and reading achievement, as well as reduced incidence of absenteeism, among low-

income students.6 We were unable to determine whether these outcomes were directly attributable to the

improvements in nutrition that SBP offers; there may be a confounding factor in that food-insufficient

students were attending school more often in order to receive the free meal. As such, though there may be

academic benefits to children and adolescents associated with HealthyMatch, we could not assign a

monetary value to said benefits.

4
School Breakfast Program (SBP). (n.d.). Retrieved from: https://www.fns.usda.gov/sbp/fact-sheet.
5
Anzman-Frasca, S., Djang, H. C., Halmo, M. M., Dolan, P. R., & Economos, C. D. (2015). Estimating impacts of a
breakfast in the classroom program on school outcomes. JAMA Pediatrics, 169(1), 71–77.
6
Dotter, D. D. (2013). Breakfast at the Desk: The Impact of Universal Breakfast Programs on Academic
Performance. Mathematica Policy Research, 1-50.

90
 Appendix AA: Sensitivity Analysis

We completed a variety of sensitivity analyses to determine how the results of our Monte Carlo

simulation changed when operating under a different set of key assumptions. These included the effect

size of the HealthyMatch program on fruit and vegetable consumption, the marginal excess tax burden

(METB), and the length of the lag on disease benefits. We varied our METB between 19 and 23 cents per

dollar. We drew these lower and upper bounds from a compilation of estimates from several studies of the

METB of federal programs.1

We also conducted sensitivity checks varying the lags on disease benefits. In our main model, we

lagged benefits from avoided cases of diabetes and depression by one year. Benefits from avoided cases

of stroke were lagged three years, and benefits from avoided cases of coronary heart disease (CHD) and

cancer were lagged five years. As noted earlier, we chose these lags due to the characteristics and natural

history of each respective disease. We also ran a sensitivity check lagging benefits attributed to each

disease by one year to procure the least conservative estimate of avoided costs of diseases. Finally, we

varied the program effect size in several ways: in our main model, we assumed a program effect size of

1.5, meaning HealthyMatch increases fruit and vegetable consumption 1.5 times that of the Healthy

Incentives Pilot (HIP). In our sensitivity checks, we varied the effect size in two ways: in one, we

assumed that the consumption effects of the program are the same as HIP; in another, we assumed that the

program has an even greater effect size, increasing consumption threefold (meaning that consumption has

an elasticity of 1, as the amount of the incentive is approximately three times that of HIP).

In our sensitivity analyses, we found that the mean of the present value of net benefits (PVNB),

presented in the table below, remained negative across all specifications. However, different sensitivity

analyses yielded varying percentages of positive trials. Though different models generated varied

proportions of positive trials, the percent of positive trials did not exceed 5 percent across all sensitivity

models. Across the sensitivity analyses, the models that returned the highest PVNB and had the highest

1
Boardman, A. E., Greenberg, D. H., Vining, A. R., & Weimer, D. L. (2017). Cost-Benefit Analysis: Concepts and
Practice. Cambridge University Press.

91
percentage of positive trials assumed a decreased lag time before the accrual of benefits attributable to

avoided chronic disease.

Table AA.1
Present Value of Net Benefits Across all Sensitivity Analyses

METB = 0.19 PVNB

Assume program effect size of 1.5 -$14,870,000*

Assume program effect size of 1 -$14,470,000*

Assume program effect size of 3 -$21,636,772

1-year lagged disease benefits -$10,370,000*

METB = 0.23 PVNB

Assume program effect size of 1.5 -$16,420,000*

Assume program effect size of 1 -$15,660,000

Assume program effect size of 3 -$24,440,000*

1-year lagged disease benefits -$11,920,000*

* Indicates those models that yielded at least one trial with positive net benefits in the 10,000 trials, but
less than 5% of trials.

Table AA.2
Trials Yielding Positive Net Benefits Across all Sensitivity Analyses

METB = 0.19 Trials (%)

Assume program effect size of 1.5 0.12

Assume program effect size of 1 0.99

Assume program effect size of 3 0

1-year lagged disease benefits 3.75

METB = 0.23 Trials (%)

Assume program effect size of 1.5 0.05

Assume program effect size of 1 0

Assume program effect size of 3 0.5

1-year lagged disease benefits 2.04

92
 Appendix AB: Standard Errors and Uncertainty Estimations

We estimated standard errors (SEs) for most of the parameters used in our Monte Carlo

simulation to model the uncertainty of point estimates. For the parameters we believed followed a normal

distribution, we used point estimates as the mean of the distribution and SEs to estimate standard

deviations (SDs). Wherever possible, we used point estimates and SEs of the distribution from the

academic literature.

In several instances, SEs were not available. In these cases, we set our parameter distributions so

that 95.45 percent of the simulated values fell within +/- of an established percent of the point estimate

using the two-sigma rule. (See chart below of uncertainty percentages). The two-sigma rule is typically

used to establish confidence intervals (CIs) where approximately 95% of random variation in a normal

distribution falls within two-sigma, or two SDs, from the mean. The uncertainty percentages used in

establishing each sigma were based on academic literature regarding the uncertainty of each parameter

and are discussed in the appendices of individual parameter estimates. This estimation strategy acts as a

95% CI for the simulated values of the parameter distribution.

Additionally, when modeled, some values of the parameter distributions drew values beyond

inflection points. These inflection points represent bounds that restrict the range that real-world values of

the parameter take on; for example, medical expenditures do not drop below $0 and reductions in relative

risk (RR) do not exceed 1. As a result of these real-world restrictions in the values that parameters take

on, all parameter distributions were “censored” beyond these values. This means that if the Monte Carlo

simulation drew values beyond these inflection points, they would be replaced with the applicable upper

or lower bound value. For example, if the parameter distribution for diabetes medical expenditures

generated a -$101 value, it would be replaced with $0. This procedure ensured that individual parameters

did not take on unrealistic values.

Note: in the tables below, parameter distributions will have either SEs from the academic literature or
will have used an uncertainty percentage and the two-sigma estimation strategy to generate its ~95% CI.
The CI estimate is taken from the Monte Carlo simulation performed in Stata Version 15.0 SE.

93
 Table AB.1
Standard Error and Uncertainty Estimates - Costs

POINT STANDARD UNCERTAINTY

PARAMETER
ESTIMATE ERROR (%)

Upfront

Agency-incurred system design costs $6,000 10

Business-incurred system design costs $183,000 10

Retailer recruitment costs $500,000 10

Ongoing - All Years

Participant recruitment direct mail

$150,000 10
costs

Participant recruitment administrative

$30,000 10
costs

Administration costs of the nutrition

$990,000 10
incentive program

Nutrition incentive benefits paid to

SNAP beneficiaries (1x effect size; $2,040,000 10
lower bound)

Nutrition incentive benefits paid to

SNAP beneficiaries (1.5x effect size; $3,060,000 10
main model)

Nutrition incentive benefits paid to

SNAP beneficiaries (3x effect size; $6,790,000 10
upper bound)

Agency-incurred costs of working

$60,000 10
with community-based organizations

Ongoing - Year 1

Retailer training costs $300,000 10

Ongoing - Year 2 and Beyond

Annual retailer retraining costs $160,000 10

5-year aggregate opportunity cost of

$4,390,000
raising government revenue +

94
Table AB.2
Standard Error and Uncertainty Estimates - Benefits

POINT STANDARD UNCERTAINTY

PARAMETER
ESTIMATE ERROR (%)

Coronary Heart Disease (CHD)

Per person medical expenditures $6,000 27

Per person productivity losses $1,000 10

RR due to daily one-serving increase

0.96 0.015
in FV consumption

Prevalence 0.046 0.004

Incidence 0.003 12

Diabetes

Per person medical expenditures $10,000 24

Per person productivity losses $3,000 24

RR due to daily one-serving increase

0.96 0.054
in FV consumption

Prevalence 0.125 0.006

Incidence 0.007 0.0003

Stroke

Per person medical expenditures $5,000 63

Per person productivity losses $1,000 49

RR due to daily one-serving increase

0.95 0.015
in FV consumption

Prevalence 0.042 0.004

Incidence 0.008 0.003

Cancer

95
Per person medical expenditures $21,000 $5,000

Per person productivity losses

$6,000 $3,000
(absenteeism)

Per person productivity losses

$11,000 $6,000
(disability)

RR due to daily one-serving increase

0.805 to 0.975
in FV consumption*

Prevalence 0.052 0.004

Incidence* 0.005 to 0.006

Depression

Per person medical expenditures $6,000 16

Per person productivity losses $1,000 16

RR due to daily one-serving increase

0.97 0.010
in FV consumption

Prevalence 0.128 0.019

Incidence 0.014 0.037

Consumer Benefits

5-year aggregate inframarginal

$10,950,000
consumption benefit +

5-year aggregate consumer surplus

$2,170,000
benefit +

* Indicates those estimates that follow a uniform distribution, so they do not have either SE or estimated CIs
utilizing uncertainty percentages. Instead, these parameters’ distributions vary from the upper and lower bounds
specified, with all values having equal probability.
+ Indicates those estimates whose valuation are based on the calculation of other parameters and do not utilize SEs
or uncertainty percentages in their calculations.

96
 Appendix AC: Relative Risk of Diseases by Obesity Status

The information presented in this appendix offers an explanation of the relative risks (RRs) of

various diseases by obesity status. In order to avoid double counting, this information was not used in our

calculations of benefits, as the diseases included in our model are comorbid with obesity. However, it is

important to note that overweight or obese individuals are at a higher risk of disease and therefore may

incur additional direct and indirect costs attributable to those diseases. As such, the magnitude of benefits

for this cohort in terms of avoided costs of disease may be higher than reported in our model. Guh et al.

conducted a systematic meta-analysis of the incidence of comorbidities related to both obesity and

overweight.1 RRs for each disease were measured using incidence rate ratios when person-time data were

available and ratios of proportions when person-time data were not available. The researchers took the log

values of the unadjusted RRs and weighted them by the inverse of their corresponding variances to obtain

pooled RRs with 95% confidence intervals (CIs) within the overweight and obese categories. These RRs

compare disease risk between overweight individuals and healthy-weight individuals and between obese

individuals and healthy individuals. To evaluate the robustness of the results, the researchers performed

sensitivity analyses stratified on the length of follow-up, age criteria, and country. RRs for chronic

diseases related to obesity or overweight status are reported in the table below.

1
Guh, D. P., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C. L., & Anis, A. H. (2009). The incidence of co-
morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health, 9(1), 1-
20.

97
Table AC.1
Relative Comorbidity Risks Related to Being Overweight or Obese [Measure: BMI]

OVERWEIGHT OBESITY

COMORBIDITY Male Female Male Female

Type II Diabetes 2.40 (2.12-2.72) 3.92 (3.10-4.97) 6.74 (5.55-8.19) 12.41 (9.03-17.06)

Cardiovascular Diseases

Hypertension 1.28 (1.10-1.50) 1.65 (1.24-2.19) 1.84 (1.51-2.24) 2.42 (1.59-3.67)

Coronary Artery
1.29 (1.18-1.41) 1.80 (1.64-1.98) 1.72 (1.51-1.96) 3.10 (2.81-3.43)
Disease

Congestive Heart
1.31 (0.96-1.79 1.27 (0.68-2.37) 1.79 (1.24-2.59) 1.78 (1.07-2.95)
Failure

Pulmonary
1.91 (1.39-2.64) 1.91 (1.39-2.64) 3.51 (2.61-4.73) 3.51 (2.61-4.73)
Embolism

Stroke 1.23 (1.13-1.34) 1.15 (1.00-1.32) 1.51 (1.33-1.72) 1.49 (1.27-1.74)

Cancer

Colorectal 1.51 (1.37-1.67) 1.45 (1.30-1.62) 1.95 (1.59-2.39) 1.66 (1.52-1.81)

Kidney 1.40 (1.31-1.49) 1.82 (1.68-1.98) 1.82 (1.61-2.05) 2.64 (2.39-2.90)

Prostate 1.14 (1.00-1.31) n/a 1.05 (0.85-1.30) n/a

Breast n/a 1.08 (1.03-1.14) n/a 1.13 (1.05-1.22)

Ovarian n/a 1.18 (1.12-1.23) n/a 1.28 (1.20-1.36)

Endometrial n/a 1.53 (1.45-1.61) n/a 3.22 (2.91-3.56)

Pancreatic 1.28 (0.94-1.75) 1.24 (0.98-1.56) 2.29 (1.65-3.19) 1.60 (1.17-2.20)

Esophageal 1.13 (1.02-1.26) 1.15 (0.97-1.36) 1.21 (0.97-1.52) 1.20 (0.95-1.53)

Source: Guh, D. P., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C. L., & Anis, A. H. (2009). The incidence
of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health,
9(1), 1-20.

98
 Appendix AD: Monte Carlo Stata Code
********************************************************************************
*CBA NET PRESENT VALUE MONTE CARLO
*EDITED: 12/22/18
********************************************************************************

clear all

*log using "C:\Users\kassa\Documents\Stata\AAE881-CBA Project\dofiles\cbamontecarlo$_DATE.log",

replace
// change path name but keep $_DATE.log at the end

********************************************************************************
/* Note: a_ for admin costs
o_ for obesity estimates
d_ for diabetes estimates
c_ for cancer estimates
s_ for stroke estimates
cv_ for cardiovascular estimates
ni_ for nutrition incentive payments */

//SET OBSERVATIONS AND SEED

set obs 10000

set seed 40186365 //RIPHI phone number minus last two digits: 68

********************************************************************************
//GENERATE VARIABLES (to model the intervention)

//COSTS

*Interest cost adjustment for Healthy Incentives Pilot Cost Estimates

scalar cpiratio_2013 = 233.049
scalar cpiratio_2018 = 252.885
scalar interest = cpiratio_2018 / cpiratio_2013
*252.885 is the Bureau of Labor Statistics October 2018 Consumer Price Index
*233.049 is the Bureau of Labor Statistics Consumer Price Index
*https://www.bls.gov/news.release/cpi.t01.htm
*https://www.dallasfed.org/research/basics/nominal.aspx

*Uncertainty percentage for RI cost estimates (above and below)

*The sigma used to vary HIP cost estimates according to the two-sigma rule
*This ensures approximately 95% of values from the simulation fall within about
*10% of the point estimate for each cost it is utilized for
scalar h_uncert = 10

***One-time costs in year zero (Taken from Exhibit 9.3, page 176 in full HIP report)

*Systems design for businesses

*Agency-incurred costs
scalar a_sysdesagency1 = 4512 + 1339 + 77
scalar a_sysdesagency2 = a_sysdesagency1 * interest
generate a_sysdesagency = rnormal(a_sysdesagency2, a_sysdesagency2/h_uncert/2)
label var a_sysdesagency "Agency-incurred costs in systems design"
summarize a_sysdesagency
ci means a_sysdesagency, level(95)

*Systems design for businesses

*Cost of the IECR system upgrades per store, stratified by type

*To replace Xerox contractor cost incurred in the HIP report
*From Exhibit 9.8, page 188 in full HIP report

99
 scalar ritotalstores = 300
*About 300 grocery stores in RI from Association Food Dealers website
scalar ristorecost_upperbound = 577 * interest
scalar ristorecost_lowerbound = 548 *interest
*Assume these upper and lower bounds as most food providers fall into
*these categories
generate a_sysdesgrocer = runiform(ristorecost_lowerbound, ristorecost_upperbound)
generate a_sysdesinfra = ritotalstores * a_sysdesgrocer
summarize a_sysdesinfra
ci means a_sysdesinfra, level(95)

generate a_sysdescost = a_sysdesagency + a_sysdesinfra

*Retailer recruitment
*Number of stores in the HIP pilot
scalar hipstores = 130

*Cost of retailer recruitment (total column, retailer recruitment row)

*Exhibit 9.3 pg. 176 full HIP report
scalar hipretrec1 = 200668
scalar hipretrec2 = hipretrec1 * interest
generate hipretrec = rnormal(hipretrec2, hipretrec2/h_uncert/2)
label var hipretrec "HIP retailer recruitment costs"

generate a_retrec = (hipretrec / hipstores) * ritotalstores

label var a_retrec "Retailer recruitment costs"
summarize a_retrec
ci means a_retrec, level(95)
*Given current information, we make a linear assumption of
*retailer recruitment costs

***Up-front costs in year 1

*Upfront training for retailers (Year 1)

scalar hiptrainingupfront1 = 275943
scalar hiptrainingupfront2 = hiptrainingupfront1 * interest
generate a_rettrainingupfront = rnormal(hiptrainingupfront2,
hiptrainingupfront2/h_uncert/2)
label var a_rettrainingupfront "Training costs, upfront"
summarize a_rettrainingupfront
ci means a_rettrainingupfront, level(95)

***Ongoing costs in all years

*General administration
*Exhibit 9.9 cost projection in year one for state agency costs of administering HIP
*page 191 of full HIP report
*Divided by 3 because 3 states costs in the chart
scalar a_yradmin1 = 912991
scalar a_yradmin2 = a_yradmin1 * interest
generate a_yradmin = rnormal(a_yradmin2, a_yradmin2/h_uncert/2)
label var a_yradmin "Annual administrative costs"
summarize a_yradmin
ci means a_yradmin, level(95)

*Nutrition incentives paid out to participants

*Exhibit 9.2, page 174 in full HIP report
*Number of SNAP participants per month in RI
*Source: USDA
generate p_snappop_rvar = runiform(171055, 175025)
label var p_snappop_rvar "Estimated monthly SNAP participants in RI"
*175025 is the average monthly SNAP participants in RI, 2015
*171055 is the average monthly SNAP participants in RI, 2016
*Number of SNAP households per month in RI
scalar p_snaphh_point = 64966
generate p_snaphh = rnormal(p_snaphh_point, p_snaphh_point/h_uncert/2)

100
 *Monthly HIP incentive amount ($$) per household
scalar ni_mohip1 = 3.65
scalar ni_mohip2 = ni_mohip1 * interest
generate ni_mohip = rnormal(ni_mohip2, ni_mohip2/h_uncert/2)
label var ni_mohip "Estimated monthly HIP incentive"

*Fraction of HIP households per month who redeem incentives

scalar ni_monoredempt1 = .34
generate ni_monoredempt = rnormal(ni_monoredempt1, ni_monoredempt1/h_uncert/2)
*Fraction of HIP households that did not redeem HIP nutrition incentives
*in a given month

*Scale factor for sensitivity analysis of the program effect size

scalar ni_eff3 = 100/30 // three times the effect size, upper bound
scalar ni_eff1half = 45/30 // one and a half times the effect size, main model

*Without this scalar, assumes HealthyMatch has same effect size as HIP
*1.5 scalar assumes has 1.5 times the effect size as HIP

*Calculate yearly nutrition benefits paid out to participants, Effect size 3

forval i = 1/12 {

generate ni_nutincent_th`i' = p_snaphh * (ni_mohip * ni_eff3) * ///

(1 - ni_monoredempt)
*Need to calculate monthly then sum over the year
label var ni_nutincent_th`i' "Nutrition incentive benefits, month `i'"

egen ni_nutincent_total_th = rowtotal(ni_nutincent_th*)

label var ni_nutincent_total_th "Annual nutrition incentive payout, Effect size 3"
summarize ni_nutincent_total_th
ci means ni_nutincent_total_th, level(95)

*Calculate yearly nutrition benefits paid out to participants, Effect size 1.5
forval i = 1/12 {

generate ni_nutincent_fi`i' = p_snaphh * (ni_mohip * ni_eff1half) * ///

(1 - ni_monoredempt)
*Need to calculate monthly then sum over the year
label var ni_nutincent_fi`i' "Nutrition incentive benefits, month `i'"

egen ni_nutincent_total_fi = rowtotal(ni_nutincent_fi*)

label var ni_nutincent_total_fi "Annual nutrition incentive payout, Effect size 1.5"
summarize ni_nutincent_total_fi
ci means ni_nutincent_total_fi, level(95)

*Calculate yearly nutrition benefits paid out to participants, Effect size 1 (Same as
HIP)
forval i = 1/12 {

generate ni_nutincent_one`i' = p_snaphh * ni_mohip * ///

(1 - ni_monoredempt)
*Need to calculate monthly then sum over the year
label var ni_nutincent_one`i' "Nutrition incentive benefits, month `i'"

egen ni_nutincent_total_one = rowtotal(ni_nutincent_one*)

label var ni_nutincent_total_one "Annual nutrition incentive payout, Effect size One"

101
 summarize ni_nutincent_total_one
ci means ni_nutincent_total_one, level(95)

*CBO annual costs

scalar hipcbocost1 = 56929
scalar hipcbocost2 = hipcbocost1 * interest
generate a_cbocost = rnormal(hipcbocost2, hipcbocost2/h_uncert/2)
label var a_cbocost "Costs of collaborations with community-based organizations"
summarize a_cbocost
ci means a_cbocost, level(95)

*Annual participant recruitment

*Number of HIP participants
scalar hippart = 7500
*Direct mailing costs pg. 174 full HIP report
*Part of the $131,064: Household recruiting in Exhibit 9.3
scalar hippartrecsupplies1 = 118058 * 0.75
scalar hippartrecsupplies2 = hippartrecsupplies1 * interest
generate hippartrecsupplies = rnormal(hippartrecsupplies2,
hippartrecsupplies2/h_uncert/2)
label var hippartrecsupplies "HIP direct costs of participant recruitment"

*Divide total direct mailing costs by the number of HIP participants

*Per participant total mailing cost
generate a_partrecsuppliesperhh = (hippartrecsupplies / 7500)

*Divide total mailing cost by 8, assuming mailing 3 is more expensive

*by a factor of 2
scalar a_partrecmail2 = a_partrecsuppliesperhh / 8

*Divide total mailing cost by 9, assuming mailing 3 is more expensive

*by a factor of 3
scalar a_partrecmail3 = a_partrecsuppliesperhh / 9

*Create a random variable that varies between these values

generate a_partrecmail = runiform(a_partrecmail3, a_partrecmail2)

*Scale up direct costs based on number of SNAP households in RI

*Multiply by 1.5 so accrued 1.5 times over the course of a year due to churn in
*the program
generate a_partrecsupplies1 = 1.5 * a_partrecmail * p_snaphh
generate a_partrecsupplies = rnormal(a_partrecsupplies1,
a_partrecsupplies1/h_uncert/2)
label var a_partrecsupplies "Direct costs of participant recruitment, annual"
summarize a_partrecsupplies
ci means a_partrecsupplies, level(95)

*Other piece of supplies and other direct costs

scalar hippartrecoverhead1 = 118058 * 0.25
scalar hippartrecoverhead2 = hippartrecoverhead1 * interest
generate a_partrecoverhead = rnormal(hippartrecoverhead2,
hippartrecoverhead2/h_uncert/2)
label var a_partrecoverhead "Indirect costs of participant recruitment, annual"
summarize a_partrecoverhead

*Annual retailer training (year 2 and beyond only)

scalar a_retailturnover = 0.5358
scalar a_trainingannual1 = hiptrainingupfront2 * a_retailturnover
generate a_rettrainingannual = rnormal(a_trainingannual1, a_trainingannual1/h_uncert/2)
label var a_rettrainingannual "Training costs, annual"
summarize a_rettrainingannual
ci means a_rettrainingannual, level(95)

*Marginal cost of public funds (the opportunity cost of raising government revenue)
*calculated later as govrev_oppcost
scalar metb = 0.19 // change metb to perform sensitivity analysis and re-run do-file

102
 scalar mcpf = 1 + metb // 1 + marginal excess tax burden

********************************************************************************
//COST LOOP AT EFFECT SIZE ONE (LOWER BOUND)

*Over relevant time period of 10 years

forval i = 0/10 {

*On-going costs (year 2 and beyond)

* _ge for government expenditures
generate costs10yr_one_ge`i' = a_yradmin + ni_nutincent_total_one + a_cbocost + ///
a_rettrainingannual + a_partrecoverhead + a_partrecsupplies ///
if `i' > 1

*Year-one costs
replace costs10yr_one_ge`i' = a_yradmin + ni_nutincent_total_one + a_cbocost + ///
a_partrecsupplies + ///
a_partrecoverhead + a_rettrainingupfront if `i' == 1

*Up-front costs
replace costs10yr_one_ge`i' = a_sysdescost + a_retrec if `i' == 0

*Opportunity cost of public funds

generate govrev_oppcost10yr_one`i' = metb * costs10yr_one_ge`i'
generate costs10yr_one`i' = govrev_oppcost10yr_one`i' + costs10yr_one_ge`i'

********************************************************************************
//COST LOOP AT EFFECT SIZE ONE AND A HALF (MAIN MODEL)

*Over relevant time period of 10 years

forval i = 0/10 {

*On-going costs (year 2 and beyond)

* _ge for government expenditure
generate costs10yr_fi_ge`i' = a_yradmin + ni_nutincent_total_fi + a_cbocost + ///
a_rettrainingannual + a_partrecoverhead + a_partrecsupplies ///
if `i' > 1

*Year one costs

replace costs10yr_fi_ge`i' = a_yradmin + ni_nutincent_total_fi + a_cbocost + ///
a_partrecsupplies + ///
a_partrecoverhead + a_rettrainingupfront if `i' == 1

*Up-front costs
replace costs10yr_fi_ge`i' = a_sysdescost + a_retrec if `i' == 0

*Opportunity cost of public funds

generate govrev_oppcost10yr_fi`i' = metb * costs10yr_fi_ge`i'
generate costs10yr_fi`i' = govrev_oppcost10yr_fi`i' + costs10yr_fi_ge`i'

********************************************************************************
//COST LOOP AT EFFECT SIZE THREE (UPPER BOUND)

*Over relevant time period of 10 years

103
forval i = 0/10 {

*On-going costs (year 2 and beyond)

* _ge for government expenditures
generate costs10yr_th_ge`i' = a_yradmin + ni_nutincent_total_th + a_cbocost + ///
a_rettrainingannual + a_partrecoverhead + a_partrecsupplies ///
if `i' > 1

*Year one costs

replace costs10yr_th_ge`i' = a_yradmin + ni_nutincent_total_th + a_cbocost + ///
a_partrecsupplies + ///
a_partrecoverhead + a_rettrainingupfront if `i' == 1

*Upfont costs
replace costs10yr_th_ge`i' = a_sysdescost + a_retrec if `i' == 0

*Opportunity cost of public funds

generate govrev_oppcost10yr_th`i' = metb * costs10yr_th_ge`i'
generate costs10yr_th`i' = govrev_oppcost10yr_th`i' + costs10yr_th_ge`i'

********************************************************************************
//BENEFITS

*Diabetes
*Relative risk
scalar d_relriskpointest = 0.96
scalar d_relriskstandarderror = 0.05357143
generate d_relrisk = rnormal(d_relriskpointest, d_relriskstandarderror)
replace d_relrisk = 1 if d_relrisk > 1
label var d_relrisk "Relative risk of diabetes"

*Medical Expenditures
scalar d_medexppoint = 9876.70 //2018 dollars
scalar d_medexp_uncert = 24.33
generate d_medexp = rnormal(d_medexppoint, d_medexppoint/d_medexp_uncert/2)
replace d_medexp = 0 if d_medexp < 0
label var d_medexp "Annual medical expenditures for diabetes"

*Lost productivity
scalar d_prodlosspoint = 2915.28 //2018 dollars
scalar d_prodloss_uncert = 24.33
generate d_prodloss = rnormal(d_prodlosspoint,
d_prodlosspoint/d_prodloss_uncert/2)
replace d_prodloss = 0 if d_prodloss < 0
label var d_prodloss "Annual cost of productivity losses due to diabetes"

*Prevalence and Incidence

scalar d_prevalencepoint = 0.124919424
scalar d_prevalencestandarderror = 0.0055
generate d_prevalence = rnormal(d_prevalencepoint, d_prevalencestandarderror)
replace d_prevalence = 0 if d_prevalence < 0

scalar d_incidencepoint = 0.0067

scalar d_incidencestandarderror = 0.00028061
generate d_incidence = rnormal(d_incidencepoint, d_incidencestandarderror)
replace d_incidence = 0 if d_incidence < 0

*CHD
*Relative risk
scalar cv_relriskpointest = 0.96
scalar cv_relriskstandarderror = 0.01530612
generate cv_relrisk = rnormal(cv_relriskpointest, cv_relriskstandarderror)
replace cv_relrisk = 1 if cv_relrisk > 1

104
 label var cv_relrisk "Relative risk of cardiovascular disease"

*Medical Expenditures
scalar cv_medexppoint = 5720.15 // 2018 dollars
scalar cv_medexp_uncert = 27
generate cv_medexp = rnormal(cv_medexppoint, cv_medexppoint/cv_medexp_uncert/2)
replace cv_medexp = 0 if cv_medexp < 0
label var cv_medexp "Annual medical expenditures for cardiovascular disease"

*Lost productivity
scalar cv_prodlosspoint = 1034.77 // 2018 dollars
scalar cv_prodloss_uncert = 10.37
generate cv_prodloss = rnormal(cv_prodlosspoint,
cv_prodlosspoint/cv_prodloss_uncert/2)
replace cv_prodloss = 0 if cv_prodloss < 0
label var cv_prodloss "Annual cost of productivity losses due to cardiovascular
disease"

*Prevalence and Incidence

scalar cv_prevalencepoint = 0.046119623
scalar cv_prevalencestandarderror = 0.004
generate cv_prevalence = rnormal(cv_prevalencepoint, cv_prevalencestandarderror)
replace cv_prevalence = 0 if cv_prevalence < 0

scalar cv_incidencepoint = 0.00275349

scalar cv_incidence_uncert = 12
generate cv_incidence = rnormal(cv_incidencepoint,
cv_incidencepoint/cv_incidence_uncert/2)
replace cv_incidence = 0 if cv_incidence < 0

*Cancer
*Relative risk
generate c_relrisk = runiform(0.805, 0.975)
label var c_relrisk "Relative risk of cancer"

*Medical Expenditures (use newly diagnosed costs)

scalar c_medexppoint = 20466.96 // 2018 dollars
scalar c_medexpstandarderror = 4733.67 // 2018 dollars
generate c_medexp = rnormal(c_medexppoint, c_medexpstandarderror)
replace c_medexp = 0 if c_medexp < 0
label var c_medexp "Annual medical expenditures for cancer"

*Lost productivity
*Monthly cost scaled up to yearly costs
scalar c_absenteeismpoint = 494.11 * 12 //2018 dollars
scalar c_absenteeismstandarderror = 939.21 * sqrt(12) //2018 dollars
generate c_absenteeism = rnormal(c_absenteeismpoint, c_absenteeismstandarderror)
replace c_absenteeism = 0 if c_absenteeism < 0
label var c_absenteeism "Annual cost of absenteeism due to cancer"

*Monthly cost scaled up to yearly costs

scalar c_disabilitypoint = 924.64 * 12 // 2018 dollars
scalar c_disabilitystandarderror = 1645.28 * sqrt(12) //2018 dollars
generate c_disability = rnormal(c_disabilitypoint, c_disabilitystandarderror)
replace c_disability = 0 if c_disability < 0
label var c_disability "Annual cost of short term disability due to cancer"

*Prevalence and Incidence

scalar c_prevalencepoint = 0.052279783
scalar c_prevalencestandarderror = 0.0035
generate c_prevalence = rnormal(c_prevalencepoint, c_prevalencestandarderror)
replace c_prevalence = 0 if c_prevalence < 0

generate c_incidence = runiform(.004581, .00583499)

105
*Stroke
*Relative risk
scalar s_relriskpoint = 0.95
scalar s_relriskstandarderror = 0.015306122
generate s_relrisk = rnormal(s_relriskpoint, s_relriskstandarderror)
replace s_relrisk = 1 if s_relrisk > 1
label var s_relrisk "Relative risk of stroke"

*Medical Expenditures
scalar s_medexppoint = 5232.21 //2018 dollars
scalar s_medexp_uncert = 63
generate s_medexp = rnormal(s_medexppoint, s_medexppoint/s_medexp_uncert/2)
replace s_medexp = 0 if s_medexp < 0
label var s_medexp "Annual medical expenditures for stroke"

*Lost productivity
scalar s_prodlosspoint = 983.72 //2018 dollars
scalar s_prodloss_uncert = 49
generate s_prodloss = rnormal(s_prodlosspoint,
s_prodlosspoint/s_prodloss_uncert/2)
replace s_prodloss = 0 if s_prodloss < 0
label var s_prodloss "Annual cost of productivity losses due to stroke"

*Prevalence and Incidence

scalar s_prevalencepoint = 0.041679682
scalar s_prevalencestandarderror = 0.0035
generate s_prevalence = rnormal(s_prevalencepoint, s_prevalencestandarderror)
replace s_prevalence = 0 if s_prevalence < 0

scalar s_incidencepoint = 0.0084712

scalar s_incidencestandarderror = 0.00328252
generate s_incidence = rnormal(s_incidencepoint, s_incidencestandarderror)
replace s_incidence = 0 if s_incidence < 0

*Depression
*Relative risk
scalar de_relriskpoint = 0.97
scalar de_relriskstandarderror = 0.01020408
generate de_relrisk = rnormal(de_relriskpoint, de_relriskstandarderror)
replace de_relrisk = 1 if de_relrisk > 1
label var de_relrisk "Relative risk of depression"

*Medical Expenditures
scalar de_medexppoint = 6575.40 //2018 dollars
scalar de_medexp_uncert = 16.87
generate de_medexp = rnormal(de_medexppoint, de_medexppoint/de_medexp_uncert/2)
replace de_medexp = 0 if de_medexp < 0
label var de_medexp "Annual medical expenditures for depression"

*Lost productivity
scalar de_prodlosspoint = 1704.16 //2018 dollars
scalar de_prodloss_uncert = 16.87
generate de_prodloss = rnormal(de_prodlosspoint,
de_prodlosspoint/de_prodloss_uncert/2)
replace de_prodloss = 0 if de_prodloss < 0
label var de_prodloss "Annual cost of productivity losses due to depression"

*Prevalence and Incidence

scalar de_prevalencepoint = 0.128
scalar de_prevalencestandarderror = 0.0194
generate de_prevalence = rnormal(de_prevalencepoint, de_prevalencestandarderror)
replace de_prevalence = 0 if de_prevalence < 0

scalar de_incidencepoint = 0.014

scalar de_incidencestandarderror = 0.0357
generate de_incidence = rnormal(de_incidencepoint, de_incidencestandarderror)

106
 replace de_incidence = 0 if de_incidence < 0

*Effect size of eating fruits and vegetables, in cups

*From Full HIP Report, pg. 202 part 10.1
scalar fv_cups = 0.24
scalar fv_cups_main = fv_cups * 1.5
scalar fv_cups_ub = fv_cups * 3
scalar grams_pcup = 136.3293

scalar serv_cups = 106

scalar c_serv_cups = 100

scalar fv_effectmain = (fv_cups_main * grams_pcup) / serv_cups

scalar fv_effectlb = (fv_cups * grams_pcup) / serv_cups
scalar fv_effectub = (fv_cups_ub * grams_pcup) / serv_cups

scalar c_fv_effectmain = (fv_cups_main * grams_pcup) / c_serv_cups

scalar c_fv_effectlb = (fv_cups * grams_pcup) / c_serv_cups
scalar c_fv_effectub = (fv_cups_ub * grams_pcup) / c_serv_cups

*Direct consumer surplus from increased fruit and vegetable consumption

*Numbers needed for calculation in the model
scalar fv_control_cups = 0.91
scalar cs_multiplier_main = fv_cups_main / (fv_cups_main + fv_control_cups)
scalar cs_multiplier_lb = fv_cups / (fv_cups + fv_control_cups)
scalar cs_multiplier_ub = fv_cups_ub / (fv_cups_ub + fv_control_cups)

*Inframarginal consumption benefit (see benefits loop = inframarg)

scalar infra_multiplier_main = fv_control_cups / (fv_cups_main + fv_control_cups)
scalar infra_multiplier_lb = fv_control_cups / (fv_cups + fv_control_cups)
scalar infra_multiplier_ub = fv_control_cups / (fv_cups_ub + fv_control_cups)

********************************************************************************
//BENEFITS LOOP FOR MAIN MODEL

/* Over the relevant time period of 10 years, take baseline SNAP risk and then
subtract out the reduced risk from consuming additional serving of fruits and
vegetables induced by the program */

*By separate disease category & lagged benefits

forval i = 0/10 {

generate benefits10yr_`i'_d = (d_medexp + d_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - d_prevalence) * d_incidence * ///
((1 - d_relrisk) * fv_effectmain)) if `i' > 1

generate benefits10yr_`i'_cv = (cv_medexp + cv_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - cv_prevalence) * cv_incidence *
///
((1 - cv_relrisk) * fv_effectmain)) if `i' > 5

generate benefits10yr_`i'_c = (c_medexp + c_absenteeism + c_disability) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - c_prevalence) * c_incidence * ///
((1 - c_relrisk) * c_fv_effectmain)) if `i' > 5

generate benefits10yr_`i'_s = (s_medexp + s_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - s_prevalence) * s_incidence * ///
((1 - s_relrisk) * fv_effectmain)) if `i' > 3

generate benefits10yr_`i'_de = (de_medexp + de_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - de_prevalence) * de_incidence *
///

107
 ((1 - de_relrisk) * c_fv_effectmain)) if `i' > 1

generate consumersurplus10yr_fi_`i' = 0.5 * ni_nutincent_total_fi * cs_multiplier_main if

`i' > 0

generate inframarg10yr_fi_`i' = ni_nutincent_total_fi * infra_multiplier_main if `i' > 0

egen total_benefits10yr_`i' = rowtotal(benefits10yr_`i'_d benefits10yr_`i'_cv

benefits10yr_`i'_c benefits10yr_`i'_s benefits10yr_`i'_de consumersurplus10yr_fi_`i'
inframarg10yr_fi_`i')

********************************************************************************
********************************************************************************
********************************************************************************
//MAIN MODEL: EFFECT SIZE 1.5
//PRESENT VALUE OF NET BENEFITS, AND DISTRIBUTION OF BENEFITS

*Discount rates of 3.5%

scalar discount_rate_3 = .035

*For the 10 year time horizon

forval i = 0/10 {

generate pvnb10yr_3_`i' = (total_benefits10yr_`i' - costs10yr_fi`i')/(1 +

discount_rate_3)^(`i'-0.5)
replace pvnb10yr_3_`i' = (total_benefits10yr_`i' - costs10yr_fi`i') if `i' == 0
label var pvnb10yr_3_`i' "Net benefits, year `i'"

egen pvnb10yr_3 = rowtotal(pvnb10yr_3_0-pvnb10yr_3_10)

//CALCULATION OF MEANS OF BENEFITS- 10 years

//Total
egen benefits10yr_macro = rowtotal(total_benefits10yr_*)
summarize benefits10yr_macro

//By disease
egen d_benefits10yr_macro = rowtotal(benefits10yr_0_d benefits10yr_1_d
benefits10yr_2_d ///
benefits10yr_3_d benefits10yr_4_d benefits10yr_5_d ///
benefits10yr_6_d benefits10yr_7_d benefits10yr_8_d benefits10yr_9_d
benefits10yr_10_d)
summarize d_benefits10yr_macro

egen cv_benefits10yr_macro = rowtotal(benefits10yr_0_cv benefits10yr_1_cv

benefits10yr_2_cv ///
benefits10yr_3_cv benefits10yr_4_cv benefits10yr_5_cv benefits10yr_6_cv ///
benefits10yr_7_cv benefits10yr_8_cv benefits10yr_9_cv benefits10yr_10_cv)
summarize cv_benefits10yr_macro

egen c_benefits10yr_macro = rowtotal(benefits10yr_0_c benefits10yr_1_c

benefits10yr_2_c ///
benefits10yr_3_c benefits10yr_4_c benefits10yr_5_c benefits10yr_6_c ///
benefits10yr_7_c benefits10yr_8_c benefits10yr_9_c benefits10yr_10_c)
summarize c_benefits10yr_macro

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 egen s_benefits10yr_macro = rowtotal(benefits10yr_0_s benefits10yr_1_s
benefits10yr_2_s ///
benefits10yr_3_s benefits10yr_4_s benefits10yr_5_s benefits10yr_6_s ///
benefits10yr_7_s benefits10yr_8_s benefits10yr_9_s benefits10yr_10_s)
summarize s_benefits10yr_macro

egen de_benefits10yr_macro = rowtotal(benefits10yr_0_de benefits10yr_1_de

benefits10yr_2_de ///
benefits10yr_3_de benefits10yr_4_de benefits10yr_5_de benefits10yr_6_de ///
benefits10yr_7_de benefits10yr_8_de benefits10yr_9_de benefits10yr_10_de)
summarize de_benefits10yr_macro

//By other benefit category

egen cs_surplus10yr_macro = rowtotal(consumersurplus10yr_fi_*)
summarize cs_surplus10yr_macro

egen if_inframarg10yr_macro = rowtotal(inframarg10yr_fi_*)

summarize if_inframarg10yr_macro

ssc install blindschemes

set scheme plottig

//CALCULATION OF MEANS
summarize pvnb10yr_3
local m10yr_3 = r(mean)

histogram pvnb10yr_3, percent xlab(, format(%20.0f)) xtitle("Present Value of Net

Benefits") ///
ytitle("Percent of trials") xline(`m10yr_3', lc(red)) xline(0, lc(blue)) fc(green) ///
title("Net Benefits of HealthyMatch over 10 years, 3.5% discount rate")

//COST HISTOGRAM
egen total_cost10yrfi = rowtotal(costs10yr_fi*)

histogram total_cost10yrfi, percent xlab(, format(%20.0f)) xtitle("Total Program Costs")

///
ytitle("Percent of trials") xline(0) fc(green) ///
title("Costs of HealthyMatch over 10 years, 1.5 Effect Size")

//BENEFIT HISTOGRAM
egen total_bene10yr = rowtotal(total_benefits10yr_*)

histogram total_bene10yr, percent xlab(, format(%20.0f)) xtitle("Avoided Costs due to

Healthy Match") ///
ytitle("Percent of trials") xline(0) fc(green) ///
title("Benefits of HealthyMatch over 10 years")

********************************************************************************
********************************************************************************
********************************************************************************
//SENSITIVITY CHECK A FOR MAIN MONTE CARLO RESULTS
// ASSUMING 1 YEAR LAG ON ALL DISEASE BENEFITS

//BENEFITS LOOP

*For the 10 year time horizon

forval i = 0/10 {

generate benefits10yrrobusta_`i'_d = (d_medexp + d_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - d_prevalence) * d_incidence * ///
((1 - d_relrisk) * fv_effectmain)) if `i' > 1

109
 generate benefits10yrrobusta_`i'_cv = (cv_medexp + cv_prodloss) * ///
((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - cv_prevalence) * cv_incidence *
///
((1 - cv_relrisk) * fv_effectmain)) if `i' > 1

generate benefits10yrrobusta_`i'_c = (c_medexp + c_absenteeism + c_disability) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - c_prevalence) * c_incidence * ///
((1 - c_relrisk) * c_fv_effectmain)) if `i' > 1

generate benefits10yrrobusta_`i'_s = (s_medexp + s_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - s_prevalence) * s_incidence * ///
((1 - s_relrisk) * fv_effectmain)) if `i' > 1

generate benefits10yrrobusta_`i'_de = (de_medexp + de_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - de_prevalence) * de_incidence *
///
((1 - de_relrisk) * c_fv_effectmain)) if `i' > 1

generate consumersurplus10yrrobusta_fi_`i' = 0.5 * ni_nutincent_total_fi *

cs_multiplier_main if `i' > 0

generate inframarg10yrrobusta_fi_`i' = ni_nutincent_total_fi * infra_multiplier_main if

`i' > 0

egen total_benefits10yrrobusta_`i' = rowtotal(benefits10yrrobusta_`i'_d

benefits10yrrobusta_`i'_cv benefits10yrrobusta_`i'_c benefits10yrrobusta_`i'_s
benefits10yrrobusta_`i'_de consumersurplus10yrrobusta_fi_`i' inframarg10yrrobusta_fi_`i')

//SENSITIVITY CHECK A: PRESENT VALUE OF NET BENEFITS & DISTRIBUTION OF BENEFITS

*For the 10 year time horizon

forval i = 0/10 {

generate pvnb10yrrobusta_3_`i' = (total_benefits10yrrobusta_`i' -

costs10yr_fi`i')/(1 + discount_rate_3)^(`i'-0.5)
replace pvnb10yrrobusta_3_`i' = (total_benefits10yrrobusta_`i' - costs10yr_fi`i')
if `i' == 0
label var pvnb10yrrobusta_3_`i' "Net benefits, year `i', sensitivity A"

egen pvnb10yrrobusta_3 = rowtotal(pvnb10yrrobusta_3_0-pvnb10yrrobusta_3_10)

ssc install blindschemes

set scheme plottig

summarize pvnb10yrrobusta_3
local m10yrrobusta_3 = r(mean)

histogram pvnb10yrrobusta_3, percent xlab(, format(%20.0f)) xtitle("Present Value of Net

Benefits") ///
ytitle("Percent of trials") xline(`m10yrrobusta_3') xline(0) fc(green) ///
title("Net Benefits of HealthyMatch over 10 years, 3.5% discount rate & 1 year lagged
benefits")

********************************************************************************
********************************************************************************
//SENSITIVITY CHECK B FOR MAIN MONTE CARLO RESULTS
//ASSUMING A GREATER EFFECT OF FRUIT AND VEGETABLE CONSUMPTION INDUCED BY THE PROGRAM

110
//THREE TIMES THE EFFECT

//BENEFITS LOOP

*For the 10 year time horizon

forval i = 0/10 {

generate benefits10yrrobustb_`i'_d = (d_medexp + d_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - d_prevalence) * d_incidence * ///
((1 - d_relrisk) * fv_effectub)) if `i' > 1

generate benefits10yrrobustb_`i'_cv = (cv_medexp + cv_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - cv_prevalence) * cv_incidence *
///
((1 - cv_relrisk) * fv_effectub)) if `i' > 5

generate benefits10yrrobustb_`i'_c = (c_medexp + c_absenteeism + c_disability) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - c_prevalence) * c_incidence * ///
((1 - c_relrisk) * c_fv_effectub)) if `i' > 5

generate benefits10yrrobustb_`i'_s = (s_medexp + s_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - ni_monoredempt) * ///
(1 - s_prevalence) * s_incidence * ((1 - s_relrisk) * fv_effectub)) if `i' > 3

generate benefits10yrrobustb_`i'_de = (de_medexp + de_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - de_prevalence) * de_incidence *
///
((1 - de_relrisk) * c_fv_effectub)) if `i' > 1

generate consumersurplus10yrrobustb_th_`i' = 0.5 * ni_nutincent_total_th *

cs_multiplier_ub if `i' > 0

generate inframarg10yrrobustb_th_`i' = ni_nutincent_total_th * infra_multiplier_ub if `i'

> 0

egen total_benefits10yrrobustb_`i' = rowtotal(benefits10yrrobustb_`i'_d

benefits10yrrobustb_`i'_cv benefits10yrrobustb_`i'_c benefits10yrrobustb_`i'_s
benefits10yrrobustb_`i'_de consumersurplus10yrrobustb_th_`i' inframarg10yrrobustb_th_`i')

//SENSITIVITY CHECK B: PRESENT VALUE OF NET BENEFITS & DISTRIBUTION OF BENEFITS

*For the 10 year time horizon

forval i = 0/10 {

generate pvnb10yrrobustb_3_`i' = (total_benefits10yrrobustb_`i' -

costs10yr_th`i')/(1 + discount_rate_3)^(`i'-0.5)
replace pvnb10yrrobustb_3_`i' = (total_benefits10yrrobustb_`i' - costs10yr_th`i')
if `i' == 0
label var pvnb10yrrobustb_3_`i' "Net benefits, year `i', sensitivity B"

egen pvnb10yrrobustb_3 = rowtotal(pvnb10yrrobustb_3_0-pvnb10yrrobustb_3_10)

ssc install blindschemes

set scheme plottig

111
 summarize pvnb10yrrobustb_3
local m10yrrobustb_3 = r(mean)

histogram pvnb10yrrobustb_3, percent xlab(, format(%20.0f)) xtitle("Present Value of Net

Benefits") ///
ytitle("Percent of trials") xline(`m10yrrobustb') fc(green) ///
title("Net Benefits of HealthyMatch over 10 years, 3.5% discount rate & increased veggie
consumption")

********************************************************************************
********************************************************************************
//SENSITIVITY CHECK C FOR MAIN MONTE CARLO RESULTS
//ASSUMING THE SAME EFFECT ON FRUIT AND VEGETABLE CONSUMPTION INDUCED BY THE HEALTHYMATCH PROGRAM
AS IN HIP

//BENEFITS LOOP

*For the 10 year time horizon

forval i = 0/10 {

generate benefits10yrrobustc_`i'_d = (d_medexp + d_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - d_prevalence) * d_incidence * ///
((1 - d_relrisk) * fv_effectlb)) if `i' > 1

generate benefits10yrrobustc_`i'_cv = (cv_medexp + cv_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - cv_prevalence) * cv_incidence *
///
((1 - cv_relrisk) * fv_effectlb)) if `i' > 5

generate benefits10yrrobustc_`i'_c = (c_medexp + c_absenteeism + c_disability) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - c_prevalence) * c_incidence * ///
((1 - c_relrisk) * c_fv_effectlb)) if `i' > 5

generate benefits10yrrobustc_`i'_s = (s_medexp + s_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - ni_monoredempt) * ///
(1 - s_prevalence) * s_incidence * ((1 - s_relrisk) * fv_effectlb)) if `i' > 3

generate benefits10yrrobustc_`i'_de = (de_medexp + de_prodloss) * ///

((p_snappop_rvar * (1 - ni_monoredempt)) * (1 - de_prevalence) * de_incidence *
///
((1 - de_relrisk) * c_fv_effectlb)) if `i' > 1

generate consumersurplus10yrrobustc_1_`i' = 0.5 * ni_nutincent_total_one *

cs_multiplier_lb if `i' > 0

generate inframarg10yrrobustc_1_`i' = ni_nutincent_total_one * infra_multiplier_lb if `i'

> 0

egen total_benefits10yrrobustc_`i' = rowtotal(benefits10yrrobustc_`i'_d

benefits10yrrobustc_`i'_cv benefits10yrrobustc_`i'_c benefits10yrrobustc_`i'_s
benefits10yrrobustc_`i'_de consumersurplus10yrrobustc_1_`i' inframarg10yrrobustc_1_`i')

//SENSITIVITY CHECK C: PRESENT VALUE OF NET BENEFITS & DISTRIBUTION OF BENEFITS

*For the 10 year time horizon

forval i = 0/10 {

112
 generate pvnb10yrrobustc_3_`i' = (total_benefits10yrrobustc_`i' -
costs10yr_one`i')/(1 + discount_rate_3)^(`i'-0.5)
replace pvnb10yrrobustc_3_`i' = (total_benefits10yrrobustc_`i' - costs10yr_one`i')
if `i' == 0
label var pvnb10yrrobustc_3_`i' "Net benefits, year `i', sensitivity C"

egen pvnb10yrrobustc_3 = rowtotal(pvnb10yrrobustc_3_0-pvnb10yrrobustc_3_10)

ssc install blindschemes

set scheme plottig

summarize pvnb10yrrobustc_3
local m10yrrobustc_3 = r(mean)

histogram pvnb10yrrobustc_3, percent xlab(, format(%20.0f)) xtitle("Present Value of Net

Benefits") ///
ytitle("Percent of trials") xline(`m10yrrobustb') fc(green) ///
title("Net Benefits of HealthyMatch over 10 years, 3.5% discount rate & no change in
veggie consumption")

********************************************************************************
********************************************************************************

//CALCULATING PERCENT OF POSITIVE TRIALS

count if pvnb10yr_3 > 0

count if pvnb10yrrobusta_3 >0

count if pvnb10yrrobustb_3 >0

count if pvnb10yrrobustc_3 >0

********************************************************************************
********************************************************************************
********************************************************************************

113