Testimony of Rachel Metz, Research and Data Manager
DC Action for Children
Performance Oversight Hearing
Fiscal Year 2021
Department of Health
Before the Committee on Health
Council of the District of Columbia
Friday, March 19, 2021
Good morning, Councilmember Gray and members of the Committee on Health. Thank you for the opportunity to address the Council as it reviews the Fiscal Year 2021 performance of the Department of Health. I am Rachel Metz, Research and Data Manager of DC Action.
DC Action uses research, data, and a racial equity lens to break down barriers that stand in the way of all kids reaching their full potential. Our collaborative advocacy initiatives bring the power of young people and all residents to raise their voices to create change. We are also the home of DC KIDS COUNT, an online resource that tracks key indicators of child and youth well-being.
Chair Gray, we want to thank DC Health for its immediate actions to ensure that DC residents who receive WIC were able to continue receiving benefits during the COVID-19 pandemic without taking further action, as well as for implementing a phone application option for DC residents newly in need of the program. We thank the DC Council and Mayor Bowser for their commitment to meeting this clear need.
In DC, WIC is one tool among many to help counter the effects of historic and ongoing racial inequity. Consistently throughout the pandemic, one in ten District households with children said that they sometimes or often didn’t have enough food that week. Some weeks, more than one in four District households with children struggled with getting enough food. For Black families the situation was even worse, with 41% reporting insufficient food some weeks during the pandemic.
Even worse, there’s reason to be concerned that families who could benefit from WIC may not be participating in the program. According to the most recent pre-pandemic publicly available data, less than half of eligible DC residents are enrolled in WIC (45.7% in 2017), which is a lower share than in neighboring Maryland and than the national average. There are policies and strategies the District could employ to enhance the ability to reach and retain District families with low incomes and link them to much needed assistance. Below are a few strategies that DHS could try to broaden its reach to eligible families.
- Prevent stigma
While for now most states still use paper vouchers, WIC is in the process of transitioning to electronic benefits cards (EBT), which simplify WIC transactions in the checkout line, eliminate the stigma of paying with paper vouchers, enable stronger agency program management and oversight and, during the COVID-19 pandemic in particular, allow for online purchases. DC WIC still uses paper vouchers, but committed to convert to EBT in 2020. The agency is still working to finish that transition, presumably due to the COVID-19 pandemic. Once eWIC is implemented, the agency must ensure that the system is compatible with the WICShopper app that some DC WIC participants use to find eligible foods and WIC retail locations and check the balance in their eWIC account.
- Increase outreach
Once an infant turns one, many participants drop out of WIC. The participation rates for children ages one to four is lower each year children age. Understanding the reasons for the decline can help government officials develop strategies to keep those eligible infants and children on the program past their first birthdays. One option for the District, as part of the development of the new Early Childhood Integrated Data System (ECIDS), is to create linkages and partnerships with SNAP agencies to forge a strong connection between families on SNAP to WIC and vice versa. In addition, medical providers can be educated about the significant benefits of WIC (for example, WIC is not just an infant formula program) so they can help connect pregnant parents, and parents of infants, and children to this critical benefit.
- Streamline nutrition education requirements
In national surveys and focus groups, WIC participants’ biggest complaints were about the in-office requirement for nutrition education and that the nutrition education material was not helpful. DC WIC, similar to Maryland WIC, has implemented an online nutrition education component which allows participants to meet their nutrition education requirements when it’s convenient to them, which should reduce barriers to meeting the requirement. In its WIC plan, the District reported conducting outreach with Arizona WIC staff regarding training and technical assistance to improve online nutrition education. We encourage the continuation of these efforts.
In addition, during the COVID-19 pandemic, the nutrition education component has been waived for participants. Telemedicine and virtual video-conferencing appointments have been successful and we recommend this delivery approach continue during and after the pandemic.
Women, Infants, and Children (WIC) Program
What is WIC?
Across the country, and particularly in the District of Columbia, fewer adults and children are participating in the federal-state Women, Infants, and Children (WIC) Program. This dangerous downward trend deprives thousands of the District’s children living in low-income households of the benefits of WIC, which are important to their healthy growth and development. Good nutrition is important in all stages of life, but particularly in the earliest years, when it serves as a critical foundation to a healthy future.
The Special Supplemental Nutrition Program for Women, Infants and Children, commonly referred to as WIC, is a public health nutrition program that provides nutritious foods, nutrition education, breastfeeding support, and health care referrals to low-income adults1, infants, and children up to age five who are at nutritional risk. WIC improves birth outcomes and enhances nutrition, health care, and cognitive development for children. WIC is a federally funded program - with annual discretionary funding voted on by Congress - that operates in all 50 states, the District of Columbia, U.S. territories, and Native reservations.2 Unfortunately, nearly two-thirds of children and pregnant parents in the District who are eligible for WIC miss out on the beneficial program. The District must reframe the narrative around WIC to emphasize it as a health benefit and one tool among many to combat the negative impacts of poverty and food insecurity on families and children in the District.
Who is WIC intended to help?
WIC provides pregnant parents, breastfeeding and non-breastfeeding postpartum parents, infants, and children up to the age of five who live in low-income households with nutritious foods, nutrition education and counseling, and referrals to health care and social services.3 Due to the legacy of discrimination and racism, individuals who earn lower incomes are disproportionately Black and Latinx. According to the most recent Census estimates, the median income for the District’s white households is almost four times that of Black households and more than twice that of Latinx households ($215,719 vs $55,301 and $85,737), with even bigger gaps for households with children. Given that disparity, Black residents are almost four times and Latinx residents are more than twice as likely as white residents to live in poverty (25.6 and 12% vs. 5.9%).4
Under the law, children and pregnant, postpartum, and breastfeeding adults are eligible for the program if their household income is at or below 185 percent of the federal poverty line or if they participate in safety net programs such as Medicaid (called DC Healthy Families), the Supplemental Nutrition Assistance Program (SNAP), or Temporary Assistance for Needy Families (TANF). In addition to being income-eligible, applicants must be at nutritional risk (e.g., underweight, overweight, anemic, poor dietary intake) as determined through a nutrition assessment conducted by a health professional. Roughly 73 percent of people approved for WIC benefits also receive benefits from another safety net program.5
Why WIC is so important
Poor nutrition during the critical first five years of a child’s life can negatively impact child health and development in both the short and long terms and hinder adult achievement and productivity.6 In the District of Columbia, WIC is one tool among many to help counter the continuing impact of historic and ongoing racial inequity affecting infants and young children. Research shows that WIC participation contributes to healthier births, improved infant feeding practices, more nutritious diets, better access to health care for children, and academic development.
Healthier births: WIC aims to ensure that pregnant parents get the food they need to deliver healthy babies, refers parents to essential medical care, and encourages the adoption of healthy behaviors. Study after study has shown that participation in WIC during pregnancy is associated with longer gestations, higher birth weights, and generally healthier infants.7 A study in South Carolina found that the positive effects of participation were greater for Black mothers. WIC participation is associated with lower odds of stillbirth among Black parents.9 This means that WIC may be a critical component in the battle against racial health disparities facing Black pregnant parents.
Improved infant feeding practices: WIC supports infant feeding that is consistent with American Academy of Pediatrics recommendations by excluding cow’s milk from infant food packages, and introducing infant cereal, fruits, and vegetables at six months (but not earlier).10 While 20 years ago, 60 percent of WIC parents introduced cereals, fruits, vegetables, or meat before 4 months, now only 20 percent do so.11
More nutritious diets: Participants can use WIC vouchers only for specific healthy foods, such as whole grains, dairy, fish, peanut butter, beans, fruits, and vegetables.12 Studies show that WIC participants consumed more servings of fruits and vegetables than nonparticipants.13 There is strong evidence that WIC participation increases infants’ and children’s intake of essential vitamins and minerals.14
Better access to primary and preventative healthcare for children: Children who participate in WIC are more likely to have well-child and sick visits than similar nonparticipants, and also more likely to be diagnosed and treated for common childhood illnesses (e.g., ear infection, upper respiratory infection, asthma).15
Improved academic development: Children whose parents participated in WIC while pregnant scored higher on assessments of mental development at age two than similar children whose parents did not participate. Furthermore, the benefits associated with WIC participation continued into the school years. Children whose parents participated in WIC while pregnant with them performed better on reading assessments.16
WIC also promotes breastfeeding as the ideal infant feeding choice and supports parents along their journey. Parents who choose to breastfeed receive counseling, educational materials, and peer support including follow-up support from other parents with personal experience. WIC provides breastfeeding parents with an enhanced food package, longer eligibility, and breast pumps.17 The District’s WIC breastfeeding initiation rate recently showed a 5% increase over the previous year from 57% in 2017 to 62% in 2018 due to the peer counselor program and 24/7 access to a board-certified lactation consultant.18 WIC provides infant formula to parents who do not breastfeed.
How does WIC operate?
While WIC is federally funded and USDA’s Food and Nutrition Service (FNS) administers WIC at the federal level, grants are provided to each state. State agencies (generally public health departments) are responsible for determining participant eligibility, providing benefits and services, and authorizing vendors. In the District, WIC is operated by DC Health. To apply for WIC in the District, individuals must go to one of 15 WIC clinic sites or call the WIC office to make an appointment; during the COVID-19 public health emergency federal policy allowed, and the District used, the option of applying by phone.19 Applicants must document their identity, residence, and income or receipt of other qualifying benefits.20 Pregnant, postpartum, and breastfeeding individuals may be referred to WIC by their doctor or when they apply for Medicaid or SNAP. WIC is a time-limited program. Once approved, a family typically receives WIC benefits for six months to a year, after which they must reapply.
Four health care providers sponsor 15 WIC clinic locations throughout the District, covering all four quadrants.21
WIC is intended to be a supplemental health benefit and is not meant to provide the full array of foods that a family with young children needs. Unlike SNAP (which can be used to buy most food of participants’ choice), WIC provides vouchers for specific types of food chosen because they are generally lacking in the diets of low-income parents and young children. WIC provides a limited number of foods – such as whole grain bread, baby food, infant formula, and milk – as well as separate cash value vouchers that participants can use only to buy fruits and vegetables. The District’s WIC program has an authorized food list that provides a detailed list of approved foods, along with pictures, as well as information on foods that are not covered in DC WIC so participants are clear about what they can and cannot purchase.22 While the authorized food list is comprehensive, the handout is long and cumbersome and not something that participants can easily read or refer to while grocery shopping, although the WICShopper app mentioned in the recommendations section may help with this issue.
Who benefits from the District’s WIC program?
According to the most recent data available for fiscal year 2020, there were an average of 13,354 total participants in WIC in the District (with slight variation over the course of the year).23 This is up somewhat from an average of 11,844 total participants in fiscal year 2019, but that increases follows several year of decreasing participation.24 When looking at the national average of participation among the categories of WIC participants, the District’s participation is higher than the national average for infants and breastfeeding parents and lower for children and pregnant parents.
Below, Figure 1: District of Columbia WIC Average Participation shows the trend in average WIC participation split among the categories of WIC participants. Prior to the COVID-19 pandemic WIC participation had declined steadily in the District and nationwide, with an uptick during the public health emergency. Advocates such as DC Action, and state officials across the country, are looking into the factors that contributed to the decline in WIC participation, even during some times of high need because of a weak economy.
In the District, Black children are more likely to be living in poverty (31% vs. less than 1%).25 WIC is a vital program for making sure children - particularly those in historically underserved communities - don’t go to bed hungry. Due to the intersection of racial discrimination and socioeconomic status, 73 percent of enrollees are Black, and 25 percent are Latinx26 However, there is concern that eligible immigrant families may be hesitant to participate due to fear around the Trump administration’s change to the “Public Charge” rule despite that change now being overturned (see below).
What portion of eligible parents participate?
To understand how effective WIC is at connecting those who are eligible, we must look at the coverage rate and the percentages of pregnant parents, infants, and children eligible for WIC who receive WIC benefits.27 The coverage rates are useful measures for understanding how well WIC reaches those who may benefit from the program. Although WIC program coverage rates vary significantly across states, almost all states follow the national pattern: infants have the highest coverage rates, pregnant parents have lower coverage rates, and children have the lowest coverage rates.28 In 2017, the WIC national coverage rate was 51.1% and in the District, it was 45.7%.29 This is down from 54.5% and 54% respectively for the U.S. and District in 2016.30 The District’s coverage rate lags behind the national average as well as the coverage rate for Maryland, one of its bordering states.
Figure 2: WIC Coverage Rates shows the comparison of the District’s coverage rate compared to the national average as well as the coverage rate of bordering states Maryland and Virginia. The District is doing well in connecting eligible infants but falls behind the national average and bordering states when reaching other key eligible WIC groups.
Recommendations to improve the reach and use of the District’s WIC program
Across the country, and particularly in the District, prior to the COVID-19 pandemic WIC participation had been declining for a few years. This drop is problematic because it deprives millions of children in low-income households of the benefits of WIC, which are important to their healthy growth and development. Good nutrition is important in all stages of life, but particularly so in the earliest years, when it serves as a critical foundation to a healthy future. DC Action is researching best practices and strategies the District can use to better reach and provide good nutrition to families who need it. Below are a few of our recommendations to help increase participation in WIC.
While most states still use paper vouchers, WIC is gradually transitioning to electronic benefits cards (EBT), which simplify WIC transactions in the checkout line, eliminate the stigma of paying with paper vouchers, enable stronger agency program management and oversight and, during the COVID-19 pandemic in particular, allow for online purchases.31 DC WIC still uses paper vouchers, but committed to convert to EBT in 2020. The agency is still working to finish that transition. According to the 2020 DC WIC State Plan, the District is prioritizing the transition to eWIC to be complete in fiscal year 2020, though that is behind schedule, presumably due to the COVID-19 pandemic .32 Once eWIC is implemented, the agency must ensure that that it is compatible with the WICShopper33 app that some DC WIC participants use to find eligible foods and WIC retail locations and also check the balance in their eWIC account.
Outreach is important for improving the coverage rate. Eligible children and expecting parents have overall low coverage rates– roughly one-third of those who are eligible for WIC receive benefits. The decline in participation of eligible children is particularly puzzling because infants have high coverage rates– 89% in the District. But once an infant turns one, many participants drop off of WIC and the participation of children ages one to four drops in WIC each year. Understanding the reasons for the decline can help government officials develop strategies to keep those eligible infants and children on the program past their first birthdays. One option for the District, as part of the development of the new Early Childhood Integrated Data System (ECIDS)34 is to create linkages and partnerships with SNAP agencies to forge a strong connection between families on SNAP to WIC and vice versa. Other states have looked at innovative ways to create a link, sometimes through data-sharing agreements, between WIC and SNAP. This is a natural connection since pregnant and postpartum individuals and children on SNAP are deemed income eligible for WIC.
The District can also continue and expand its use of technology to reach eligible participants. The DC WIC website is the first place that most potential participants will go to find information on the program. The website must continue to provide clear and welcoming information for potential applicants and a platform for applicants to engage with the program directly. DC WIC can pilot the use of a chat feature and text message reminders for participants. Fully funding the WIC Expansion Act could provide resources for this type of outreach.
Medical providers are the greatest resource for referring eligible individuals to WIC and they can be educated about the significant benefits of WIC (for example, WIC is not just an infant formula program). Physicians and providers can help shape the narrative around WIC as a health program and help connect pregnant parents and parents of infants, and children to this critical benefit. DC WIC must continue to provide updated and relevant information to physicians and providers to make sure they are armed with accurate and up to date program information. As more providers start to assess social determinants of health, economic, and social factors that may impact a patient’s health, WIC is a natural referral point for physicians and providers caring for low-income individuals and young children. Clinicians who see low-income patients and ask about the family’s ability to purchase food can provide WIC and SNAP as options.
As it relates to public charge, the lingering chilling effect of the Trump administration’s expansion of the public charge rule,35 there is a lot of fear and misinformation among communities, even though the Biden administration is reversing that expansion. WIC is one of only a few safety net programs that immigrants, regardless of their immigration status, are eligible to participate in. As a result, it is critical that immigrant families in the District know that they can assess essential nutrition assistance through WIC.
Streamline Nutrition Education Requirements
In national surveys and focus groups, WIC participants’ biggest complaints were about the in-office requirement for nutrition education and that the nutrition education material was not helpful.36 DC WIC, similar to Maryland WIC, has implemented an online nutrition education component which allows participants to meet their nutrition education requirements when convenient to them, which should reduce barriers to meeting the requirement. Arizona WIC staff went a step further and added an online group for WIC participants to learn from each other. Providing online nutrition education and a peer support group was beneficial for participants and staff.37 In its WIC plan, District officials indicated that they conducted outreach with Arizona WIC staff regarding training and technical assistance to improve online nutrition education. During the COVID-19 public health emergency the nutrition education component has been waived for participants. Telemedicine and virtual video-conferencing appointments have been successful and we recommend this delivery approach continue during and post-pandemic.
1. Throughout this document we use gender neutral terminology, rather than “women” or “mothers,” to acknowledge that pregnant, postpartum, and breastfeeding individuals of any gender (including transgender men and nonbinary individuals) should be able to enroll in WIC.
2. There are currently 90 WIC State agencies: the 50 geographic states, the District of Columbia, Puerto Rico Guam, the Virgin Islands, American Samoa, Northern Marianas, and 34 Indian tribal organizations (ITO's).
3. USDA Food and Nutrition Service. (2018). Frequently Asked Questions about WIC. Available at: https://www.fns.usda.gov/wic/frequently-asked-questions-about-wic. Accessed on November, 2019.
4. KidsCount Data Center. Available at https://datacenter.kidscount.org/.
5 Center on Budget and Policy Priorities (2017). Policy Basics: Special Supplemental Nutrition Program for Women, Infants, and Children, Available at: https://www.cbpp.org/research/food-assistance/policy-basics-special-supplemental-nutrition-program-for-women-infants-and
6. Food Research & Action Center and Children’s HealthWatch. (2015). Early Childhood Nutrition Sets the Trajectory for Lifelong Health and Well- Being: WIC and the Child and Adult Care Food Program (CACFP) are Key Sources of Quality Early Nutrition. Available at: http://org2.salsalabs.com/o/5118/p/salsa/web/common/public/content?content_item_KEY=12853
7. USDA commissioned a review of more than three dozen WIC studies published between 1979 and 2004 concluded that WIC increased average birth weights, and improved several other key birth outcomes. A subsequent review of the next generation of studies published through 2010 had consistent findings that WIC increased average birth weight and reduced the incidence of low and very low birth weight.
8. Sonchak, L. The Impact of WIC on Birth Outcomes: New Evidence from South Carolina. Maternal Child Health J 20, 1518–1525 (2016). https://doi.org/10.1007/s10995-016-1951-y
9. Angley, M., Thorsten, V.R., Drews-Botsch, C. et al. Association of participation in a supplemental nutrition program with stillbirth by race, ethnicity, and maternal characteristics. BMC Pregnancy Childbirth 18, 306 (2018).
10. WIC Infant and Toddler Feeding Practices Study – 2: Infant Year Report. https://www.fns.usda.gov/wic/wic-infant-and-toddler-feeding-practices-study-2-second-year-report; The American Academy of Pediatrics recommends that parents introduce solid foods into their baby’s diet around six months and delay the introduction of cow’s milk until a child’s first birthday. Babies who start earing solid food too early are more likely to be overweight or obese later in life. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/HALF-Implementation-Guide/Age-Specific-Content/Pages/Infant-Food-and-Feeding.aspx
11. WIC Infant and Toddler Feeding Practices Study – 2: Infant Year Report. https://www.fns.usda.gov/wic/wic-infant-and-toddler-feeding-practices-study-2-second-year-report
12. DC WIC Approved Food List, available here: https://dchealth.dc.gov/node/124182
13. USDA WIC Literature Review 2012
14. Carlson, S., Neuberger, Z. WIC Works: Addressing the Nutrition and Health Needs of Low-Income Families for 40 Years. report.ttps://www.cbpp.org/research/food-assistance/wic-works-addressing-the-nutrition-and-health-needs-of-low-income-families
15. Buescher, Paul A et al. “Child participation in WIC: Medicaid costs and use of health care services.” American journal of public health vol. 93,1 (2003): 145-50. doi:10.2105/ajph.93.1.145 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447709/
16. Jackson M (2015). Early childhood WIC participation, cognitive development and academic achievement. Social Science & Medicine, available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4703081/.
17. Center on Budget and Policy Priorities WIC Policy Basics. https://www.cbpp.org/research/food-assistance/policy-basics-special-supplemental-nutrition-program-for-women-infants-and
18. National WIC Association DC WIC state profile https://s3.amazonaws.com/aws.upl/nwica.org/2019-dc-wic-fact-sheet.pdf.
19. DC WIC website, clinic locations: available at: https://www.dcwic.org/wic-locations. Information on USDA COVID-19 waivers is available at https://www.fns.usda.gov/wic/extension-certain-approved-COVID-19-waivers
21. Unity Health Care. Inc, Children’s National Health System, Mary’s Center for Maternal and Child Care, and Howard University Hospital are the four providers as of December 2019. The four providers together, sponsor 15 WIC clinic locations the Information available here: https://dchealth.dc.gov/service/special-supplemental-nutrition-program-women-infants-and-children-wic
22. DC WIC Approved Food List, available here: https://www.dcwic.org/wic-foods
23. USDA/FNS WIC FY 2019 data table, available at: https://fns-prod.azureedge.net/pd/wic-program
24. USDA/FNS WIC FY 2018 data table, available at: https://fns-prod.azureedge.net/pd/wic-program
25. KidsCount Data Center. Available at https://datacenter.kidscount.org/data/tables/8447-children-in-poverty-100-by-age-group-and-race-and-ethnicity?loc=10&loct=3#detailed/3/any/false/37,871,870,573,869,36,133,35,16/2757,4087,3654,3301,2322,3307,2664|140/17079,17080
26. WIC Racial-Ethnic Group Enrollment Data 2016. Available at https://www.fns.usda.gov/wic/wic-racial-ethnic-group-enrollment-data-2016. Those two groups are not mutually exclusive - someone who's Afro-Latina will be counted in both groups.
27. Volume I: USDA National and State-Level Estimates of WIC Eligibility and WIC Program Reach in 2017 Final Report, December 2019 available at: https://fns-prod.azureedge.net/sites/default/files/resource-files/WICEligibles2017-Volume1.pdf
30. WIC 2016 Eligibility and Coverage Rates Data and Report: available at: https://www.fns.usda.gov/wic/wic-2016-eligibility-and-coverage-rates
31. Center on Budget and Policy Priorities WIC Policy Basics. https://www.cbpp.org/research/food-assistance/policy-basics-special-supplemental-nutrition-program-for-women-infants-and
32. DC FY 2020 Goals and Objectives https://20158fdc-f4db-4436-a8f3-8d0d4c02c740.filesusr.com/ugd/a048fe_3dbb529b080849149247299ca31041d5.pdf
33. WICShopper is a mobile app that helps WIC participants use their WIC benefits and it is the app that DC WIC uses. Participants can scan products to see if they are approved, view recipes, and more in some states. http://jpma.com/
34. DC FY 2020 Goals and Objectives https://20158fdc-f4db-4436-a8f3-8d0d4c02c740.filesusr.com/ugd/a048fe_3dbb529b080849149247299ca31041d5.pdf
35. Public charge is an element of immigration law that historically allowed federal authorities to deny legal status to individuals who are determined to be primarily dependent on the government for subsistence. The recent DHS and State Department regulations, that went into effect on February 24, 2020, redefine a “public charge” as a non-citizen who receives or is likely to receive one or more of the specified public benefits for more than 12 months in the aggregate within any 36-month period. The benefits considered are cash assistance for income maintenance form any level of government, SNAP (formerly food stamps) public housing, Section 8 housing assistance, and Medicaid (with exceptions for persons under age 21, individuals during pregnancy and for 60 days after the pregnancy ends and emergency services). This is much broader than the original test for public charge. See Protecting Immigrant Families (PIF) FAQs: https://docs.google.com/document/d/1zHLRaciDqIZfkI_icRGVJWKWcinP6cAwvkuAeae8eog/edit?usp=sharing. On Feb. 2, 2021 the Biden administration reversed this broadening, however many families may still be still confused or afraid.
36. Christie, C., Watkins, J. A., Martin, A., Jackson, H., Perkin, J. E., & Fraser, J. (2006). Assessment of client satisfaction in six urban WIC clinics. Florida Public Health Review, 3, 35–42.
37. Presentation of Arizona Department of Health Services during the WIC Child Retention Webinar. Available at: https://wicworks.fns.usda.gov/resources/wic-child-retention-webinar-presentation