This is the accessible text file for GAO report number GAO-10-346 entitled 'Domestic Food Assistance: Complex System Benefits Millions, but Additional Efforts Could Address Potential Inefficiency and Overlap among Smaller Programs' which was released on April 15, 2010. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Report to Congressional Requesters: United States Government Accountability Office: GAO: April 2010: Domestic Food Assistance: Complex System Benefits Millions, but Additional Efforts Could Address Potential Inefficiency and Overlap among Smaller Programs: GAO-10-346: GAO Highlights: Highlights of GAO-10-346, a report to congressional requesters. Why GAO Did This Study: The federal government spends billions of dollars every year on domestic food assistance programs. The U.S. Department of Agriculture administers most of these programs and monitors the prevalence of food insecurity—that is, the percentage of U.S. households that were unable to afford enough food sometime during the year. Other federal agencies also fund food assistance programs; however, comprehensive and consolidated information on the multiple programs is not readily available. Congress asked GAO to examine: 1) the prevalence of food insecurity in the United States, 2) spending on food assistance programs, 3) what is known about the effectiveness of these programs in meeting program goals, and 4) the implications of providing food assistance through multiple programs and agencies. GAO’s steps included analyzing food security and program spending data, analyzing studies on program effectiveness, analyzing relevant federal laws and regulations, conducting site visits, and interviewing relevant experts and officials. What GAO Found: The prevalence of food insecurity hovered between 10 and 12 percent over the past decade until it rose to nearly 15 percent (or about 17 million households) in 2008. Households with incomes below the poverty line, households headed by single parents, minority households, and those with children had higher than average rates of food insecurity. These households were more likely to report, for example, that they had been hungry, but didn’t eat, because there wasn’t enough money for food. While some households were able to protect children from the effects of food insecurity, many could not. In more than 4.3 million households, children—as well as adults—were affected by food insecurity sometime during the year. The federal government spent more than $62.5 billion on 18 domestic food and nutrition assistance programs in fiscal year 2008. The five largest food assistance programs—Supplemental Nutrition Assistance Program (SNAP); the National School Lunch Program; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); the Child and Adult Care Food Program; and the School Breakfast Program—accounted for 95 percent of total spending on the 18 programs. Since 1995 SNAP spending has fluctuated while spending on the other large programs has remained relatively stable. Economic conditions— such as unemployment or poverty—and other factors can affect spending on some programs, particularly SNAP. Research suggests that participation in 7 of the programs we reviewed— including WIC, the National School Lunch Program, the School Breakfast Program, and SNAP—is associated with positive health and nutrition outcomes consistent with programs’ goals, such as raising the level of nutrition among low-income households, safeguarding the health and wellbeing of the nation’s children, and strengthening the agricultural economy. However, little is known about the effectiveness of the remaining 11 programs because they have not been well studied. Federal food assistance is provided through a decentralized system that involves multiple federal, state, and local organizations. The complex network of 18 food assistance programs emerged piecemeal over the past several decades to meet various needs. Agency officials and local providers told us that the multiple food assistance programs help to increase access to food for vulnerable or target populations. However, the 18 food assistance programs show signs of program overlap, which can create unnecessary work and lead to inefficient use of resources. For example, some of the programs provide comparable benefits to similar target populations. Further, overlapping eligibility requirements create duplicative work for both service providers and applicants. Consolidating programs, however, entails difficult trade-offs. Such actions could improve efficiency and save administrative dollars but could also make it more difficult to achieve the goals of targeting service to specific populations, such as pregnant women, children, and the elderly. What GAO Recommends: We recommend that the Secretary of Agriculture identify and develop methods for addressing potential inefficiencies and reducing unnecessary overlap among smaller programs while ensuring access to the programs for those who are eligible. USDA agreed to consider the value of examining potential inefficiencies and overlap among smaller programs. View [hyperlink, http://www.gao.gov/products/GAO-10-346] or key components. For more information, contact Kay E. Brown at (202) 512- 7215 or brownke@gao.gov. [End of section] Contents: Letter: Background: Nearly Fifteen Percent of U.S. Households Were Food Insecure Sometime in 2008, According to USDA: The Federal Government Spent More Than $62.5 Billion on 18 Food Assistance Programs in Fiscal Year 2008: Research Shows 7 Programs Have Positive Outcomes Related to Their Goals but Little Is Known about the Remaining 11 Programs: The System of Multiple Programs and Agencies That Provide Food Assistance Helps Address a Variety of Needs but Can Result in Overlap and Inefficiency: Conclusion: Recommendation for Executive Action: Agency Comments and Our Evaluation: Appendix I: Objectives, Scope, and Methodology: Appendix II: The Prevalence of Food Insecurity among U.S. Households from 1995 to 2008 and the Issues Affecting Food Insecurity Data: Appendix III: Selected Program Goals: Appendix IV: Comments from the Department of Health and Human Services: Appendix V: GAO Contact and Staff Acknowledgments: Related Products: Tables: Table 1: Food Security Definitions: Table 2: Selected Federal Food and Nutrition Assistance Programs, by Agency: Table 3: Federal Spending on 18 Food and Nutrition Assistance Programs: Table 4: Amount of Research Identified on Programs: Table 5: Summary of Program Assessment Rating Tool (PART) Evaluations of the 11 Less Researched Programs: Table 6: Estimates and 90 Percent Confidence Intervals for Food Security, Low Food Security, and Very Low Food Security, 1998 to 2008: Table 7: Summary of Selected Food and Nutrition Assistance Program Goals: Figures: Figure 1: Trends in the Prevalence of Food Insecurity in U.S. Households from 1998 to 2008: Figure 2: Food Insecurity among U.S. Households in 2008: Figure 3: Groups for Which Rates of Food Insecurity Were Higher Than the National Average in 2008: Figure 4: Percentage of Food Assistance Spending by Program in Fiscal Year 2008: Figure 5: Spending on the Five Largest Programs from 1995 to 2008, Adjusted to 2008 Dollars: Figure 6: Spending on SNAP, with Federal Poverty and Unemployment Rates, Fiscal Years 1995 to 2008: Figure 7: Entities That Administer Federal Food Assistance Programs in Texas: Figure 8: Program Participation of Low-Income Households with Low or Very Low Food Security, 2007-2008: Figure 9: Page Three of Alameda County Nutrition Action Partners' Free Food Programs Brochure: Figure 10: Programs Included and Excluded from Our Review: Figure 11: Prevalence of Food Insecurity in U.S. Households from 1995 to 2008: Abbreviations: AOA: Administration on Aging: CFFR: Consolidated Federal Funds Report: CPS: Current Population Survey: DHS: Department of Homeland Security: HHS: Department of Health and Human Services: PART: Program Assessment Rating Tool: Recovery Act: American Recovery and Reinvestment Act of 2009: SNAP: Supplemental Nutrition Assistance Program: USDA: United States Department of Agriculture: WIC: Special Supplemental Nutrition Program for Women, Infants, and Children: [End of section] United States Government Accountability Office: Washington, DC 20548: April 15, 2010: The Honorable Saxby Chambliss: Ranking Member: Committee of Agriculture, Nutrition, and Forestry: United States Senate: The Honorable George Voinovich: Ranking Member: Subcommittee on Oversight of Government Management, the Federal Workforce, and the District of Columbia: Committee on Homeland Security and Governmental Affairs: United States Senate: The Honorable Tom Coburn, M.D. United States Senate: The federal government spends billions of dollars every year on food and nutrition assistance programs, and millions of Americans turn to these federal programs when they lack the money to get enough to eat. The nation's largest food assistance program--the Supplemental Nutrition Assistance Program (SNAP)[Footnote 1]--provided more than $34.6 billion in benefits in fiscal year 2008. The recent economic crisis has increased demand for such assistance, with participation in SNAP increasing by 22 percent between June 2008 and June 2009. [Footnote 2] U.S. Department of Agriculture's (USDA) Food and Nutrition Service has responsibility for administering most of the federal domestic food and nutrition programs, including the five largest: SNAP; the National School Lunch Program; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); the Child and Adult Care Food Program; and the School Breakfast Program. As the federal government's primary domestic food assistance agency, USDA aims to help households achieve food security--that is, to have consistent, dependable access to enough food for an active, healthy life--and monitors the extent and severity of food insecurity. The Department of Health and Human Services (HHS) and the Department of Homeland Security (DHS) also fund programs that provide food and nutrition assistance. However, consolidated and comprehensive information on how much federal agencies spend to support these multiple food assistance programs and information on their effectiveness in meeting program goals is not readily available. To shed light on these issues, we addressed the following: (1) what is the prevalence of food insecurity among U.S. households; (2) how much did the federal government spend on food and nutrition assistance programs in fiscal year 2008, and how has spending on the five largest programs changed over time; (3) what is known about the effectiveness of federal food and nutrition programs in meeting program goals; and (4) what are the implications of providing food assistance through multiple programs and agencies? To address these research objectives, we collected information on all federal programs that focus primarily on providing or supporting food and nutrition assistance.[Footnote 3] We identified these programs by reviewing the Catalog of Federal Domestic Assistance,[Footnote 4] relevant federal laws and regulations, and other relevant documents, and by interviewing federal officials and experts. To show the prevalence of food insecurity among U.S. households from 1995 (when this information was first collected) to 2008 (the most current data available), we present USDA's food security estimates based on the Current Population Survey (CPS) annual food security supplement. [Footnote 5] Many of these estimates are obtained from the USDA publication Household Food Security in the United States, 2008. While the food security data have some limitations, these data provide a nationally representative measure of hunger over time, and we consider these data reliable for this engagement. To determine how much money federal agencies spent on food and nutrition programs, we analyzed data from the Consolidated Federal Funds Report (CFFR)--a database that compiles expenditures or obligations from federal agencies--as well as additional spending data provided by agencies. We confirmed the reliability and accuracy of these data with federal officials. [Footnote 6] To determine what is known about the impacts these programs have on outcomes related to their goals, we analyzed the Economic Research Service's[Footnote 7] comprehensive review of studies published between 1973 and 2002. We also conducted our own literature review that examined studies, published between January 1995 and July 2009, of programs administered by agencies other than USDA, as well as studies of USDA programs that were conducted between 2002 and July 2009. These literature reviews included peer-reviewed journal articles, agency documents, and other research determined to be methodologically rigorous and reliable. To understand the implications of providing food assistance through multiple programs and agencies, we reviewed previous reports and interviewed federal, state, and local officials, as well as local providers and other groups in five states. We conducted site visits in California, Illinois, and Maryland, where we met with local providers, including food banks, local health departments, and other public and nonprofit entities that administer federal food and nutrition assistance programs. We also conducted phone interviews with officials and providers in Oregon and Texas. The states and localities that we met with were selected to take into account geographic distribution and to include both urban and rural areas, as well as a diverse group of local agencies providing program services. We also considered recommendations from federal officials and relevant experts. (See appendix I for more information on our scope and methodology.) We conducted this performance audit from February 2009 to March 2010 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence we obtained provides a reasonable basis for our findings and conclusions. Background: Hunger and Food Insecurity: The word hunger has several meanings--it can describe, for example, one's desire for food; the painful sensation or state of weakness caused by the need for food; or famine. While severe hunger-- manifesting as clinical malnutrition--is uncommon in this country, millions of children and adults who lack resources go without food and many are undernourished. The mental and physical changes that accompany inadequate food intake and even minor nutrient deficiencies can have negative effects on learning, development, productivity, physical and psychological health, and family life. In 1995 USDA's Economic Research Service--through the nationally representative CPS Food Security Supplement--began tracking the number of households that are uncertain of having or unable to acquire enough food because they lack resources, and uses the term low food security or very low food security, not hunger, to describe these households. USDA adopted these terms in response to recommendations by a National Academies panel, which found the term hunger to be inappropriate when describing low-income households that lack enough food both because of the difficulties in measuring hunger and because hunger has physiological definitions that do not necessarily correspond to nutritional insufficiency.[Footnotes 8, 9] USDA monitors the food security status of U.S. households as part of its responsibility for administering most of the federal government's food and nutrition assistance programs, many of which are intended to alleviate food insecurity and prevent the physical and psychological outcomes--such as low birth weights, chronic illnesses, and anxiety--associated with being undernourished. To be consistent with USDA, this report uses the terms low food security, very low food security, and food insecure. (See table 1 for definitions of these terms.) The annual CPS Food Security Supplement collects data on the prevalence and severity of food insecurity by asking one adult in each household a series of questions about experiences and behaviors of household members that indicate food insecurity.[Footnote 10] The food security status of the household is assessed based on the number of food-insecure conditions reported, such as being unable to afford balanced meals and being hungry because there was too little money for food.[Footnote 11] Food-insecure households are classified as having either low food security or very low food security (see table 1). In addition, the survey assesses the food security status of households with children.[Footnote 12] Table 1: Food Security Definitions: Food security (all households): Measure: Food secure[A]; Definition: All household members had access at all times to enough food for an active, healthy life. Measure: Food insecure (low or very low food security); Definition: Household members were, at times, uncertain of having or unable to acquire enough food for all household members because they had insufficient money or other resources. Measure: Low food security; Definition: Household members avoided substantial reductions in food intake, in many cases, by relying on a few basic foods or reducing variety in their diets. Measure: Very low food security; Definition: One or more household members' eating patterns were disrupted and their food intake reduced, at least some time during the year, because they couldn't afford enough food. Food security among adults and children (in households with children): Measure: Food secure; Definition: All household members had access at all times to enough food for an active, healthy life. Measure: Food insecurity (low or very low food security) among adults only; Definition: Among food-insecure households with children, only adults were food insecure. Measure: Food insecurity (low or very low food security) among children; Definition: Among food-insecure households with children, children, too, were sometimes food insecure. Measure: Low food security among children; Definition: Children's food security was affected, primarily by reductions in the quality and variety of children's meals. Measure: Very low food security among children; Definition: Children's regular meal patterns were disrupted and food intake was reduced to less than the amount their caregivers considered adequate. Source: Economic Research Service, USDA. [A] Among households that are food secure, USDA also makes a distinction between households that have "marginal food security" and those that have "high food security." Households that have "marginal food security" reported one or two indicators of food access problems or limitations, typically of anxiety over food sufficiency or a shortage of food in the house; however, unlike food insecure households, households with marginal food security reported little or no indication of changes in diets or food intake. In contrast, households that have "high food security" reported no indicators of food access problems or limitations. [End of table] Food and Nutrition Assistance Programs: The federal government has been helping needy individuals and families access food for more than 60 years. The National School Lunch Program, for example, was authorized in 1946 and became one of the first large- scale food and nutrition assistance programs. Other federal programs followed, including the School Breakfast Program (founded by the Child Nutrition Act of 1966) and WIC, authorized in 1972. Over time, some programs have changed. For example, according to USDA, an early version of SNAP (formerly the Food Stamp Program) required eligible individuals to pay for a portion of their orange-colored stamps, which they could use for any kind of food. In addition, this early version provided eligible individuals with free blue stamps, equal to half the amount of the orange stamps, to buy designated surplus foods.[Footnote 13] Today, SNAP recipients now receive their benefits on electronic benefit transfer cards and no longer use actual stamps to purchase food. The federal government currently funds close to 70 programs that are permitted to provide at least some support for domestic food assistance.[Footnote 14] In our study, we identified the 18 programs that focus primarily on providing food and nutrition assistance to low- income individuals and households. (See table 2.) Table 2: Table 2: Selected Federal Food and Nutrition Assistance Programs, by Agency: USDA: Program: Child and Adult Care Food Program; Target population[A]: Children, elderly, and special groups: Children in certain nonresidential child care centers, family, or group day care; children in after school programs in low-income areas, or residing in emergency shelters; and chronically impaired disabled adults and persons 60 years or older in adult day care centers; Benefit type[B]: Reimburse local providers (child care centers, adult day care centers, etc.) for meals and snacks served; Participation (approx.)[C]: 3.1 million children and 108,000 adults (average daily). Program: Commodity Supplemental Food Program; Target population[A]: Children, elderly, and special groups: Low- income pregnant, postpartum, and breastfeeding women, infants, children up to age 6, and persons 60 years or older; Benefit type[B]: Supplemental foods, in the form of USDA commodities, are provided in food packages to individuals; Participation (approx.)[C]: 31,000 women, infants, children, and 444,000 elderly. 475,000 total participants (average per month). Program: Community Food Projects Competitive Grant Program[D]; Target population[A]: Individuals and families: Low-income people in participating communities; Benefit type[B]: Matching grants made to organizations to plan and implement projects to improve access of low-income community members to food/nutrition, increase the self-reliance of communities in providing for their own needs, and promote comprehensive responses to local food, farm, and nutrition issues; Participation (approx.)[C]: 290 projects have been funded between fiscal year 1997 and fiscal year 2009. Program: Food Distribution Program on Indian Reservations; Target population[A]: Special groups: American Indian and non-Indian households that reside on a reservation and Indian households living in an otherwise designated area, and recognized as having inadequate income and resources; Benefit type[B]: Food is provided to qualifying households; Participation (approx.)[C]: 90,000 participants (average per month). Program: Fresh Fruit and Vegetable Program; Target population[A]: Children: Elementary school children in designated schools with a high percentage of students eligible for free or reduced priced meals; Benefit type[B]: Reimburse local providers (elementary schools) for fresh fruit and vegetable snacks served free to students outside of breakfast or lunch periods; Participation (approx.)[C]: 1,956 schools participated during 2008- 2009 school year, with an enrollment of approximately 740,000 students. Program: National School Lunch Program; Target population[A]: Children: School children, of high school grades and younger. Students from families with incomes below 130 percent of the federal poverty level (or from families receiving SNAP) qualify for free meals, and students from families with incomes below 185 of the federal poverty level qualify for reduced price meals; Benefit type[B]: Cash grants and food donations are provided to reimburse local providers (schools) for meals and snacks served. Schools must agree to serve free and reduced price meals to eligible children; Participation (approx.)[C]: 31 million students (average daily). Program: Nutrition Assistance for Puerto Rico; Target population[A]: Special groups: Needy persons residing in the Commonwealth of Puerto Rico; Benefit type[B]: Benefits provided to households or individuals for food purchase through an electronic benefit transfer; Participation (approx.)[C]: More than 1 million individuals served in fiscal year 2004.[E] Program: School Breakfast Program; Target population[A]: Children: Eligible children in schools and residential child care institutions. Children whose families meet income eligibility guidelines qualify for free or reduced price breakfasts; Benefit type[B]: Reimburse local providers (schools and residential child care institutions) for breakfasts served; Participation (approx.)[C]: 10.6 million students served (average daily). Program: Senior Farmers' Market Nutrition Program; Target population[A]: Elderly: Low-income seniors; Benefit type[B]: Benefits can be used to purchase fresh fruits, vegetables, and herbs at authorized farmers' markets, roadside stands, and community supported agriculture programs; Participation (approx.)[C]: 953,000 low-income seniors.[F] Program: Special Milk Program; Target population[A]: Children: Children in schools, of high school grade or younger, childcare institutions, and similar nonprofit institutions that do not participate in other federal meal service programs, including the National School Lunch or School Breakfast Programs; Benefit type[B]: Formula grant, reimbursing cost of milk for children in schools, camps, and other programs that do not participate in other child nutrition programs; Participation (approx.)[C]: 5,971 schools, nonresidential child care institutions, and summer camps participated; 85.8 million half pints served. Program: Summer Food Service Program; Target population[A]: Children: Children from needy areas during summer break or when schools are closed for vacation; Benefit type[B]: Reimburse local providers (schools, government agencies, and nonprofit organizations) for meals and snacks served in programs during breaks in school year; Participation (approx.)[C]: 2.2 million children; (average daily during the month of July 2008). Program: SNAP; Target population[A]: Individuals and households: Low-income households with gross income at or below 130 percent of federal poverty level or net income at or below 100 percent of the poverty level and with limited resources; Benefit type[B]: Benefits provided to households through electronic debit card for food purchase in participating retail stores; Participation (approx.)[C]: 28.4 million people or 12.7 million households (average per month). Program: The Emergency Food Assistance Program; Target population[A]: Individuals and households: Needy individuals, such as those who may be homeless or participate in welfare programs; Benefit type[B]: Commodity foods are distributed through state agencies to food banks and other agencies, which provide food to local organizations, such as soup kitchens and food pantries, or directly provide the foods to needy households; Participation (approx.)[C]: USDA entitlement and bonus commodity foods valued at over $226 million delivered to warehouses in states and territories for distribution to local organizations.[G] Program: WIC; Target population[A]: Children and special groups: Low-income pregnant, breastfeeding, and postpartum women, infants, and children to age five determined to be at nutritional risk; Benefit type[B]: Check, voucher, or electronic benefit transfer benefits provided to recipients pay for supplemental foods, and provide nutrition education and health care referrals for participants. Some state agencies distribute WIC foods directly to recipients through warehouses or home delivery; Participation (approx.)[C]: 8.7 million women, infants, and children; (average per month). Program: WIC Farmers' Market Nutrition Program; Target population[A]: Children and special groups: WIC participants and those on a waiting list to receive WIC benefits (lower-income pregnant, breastfeeding, and postpartum women, infants, and children to age five, who are at nutritional risk); Benefit type[B]: Coupons provided for purchase of fresh fruits and vegetables at certified farmers markets; Participation (approx.)[C]: 2.2 million women, infants, and children.[F] DHS Federal Emergency Management Agency: Program: Emergency Food and Shelter National Board Program; Target population[A]: Individuals and households: Families and individuals in need of assistance; Benefit type[B]: Funds provided to private and independent nonprofit or public organizations (such as community action agencies, food banks, and food pantries) to provide emergency food and shelter to families and individuals in need of assistance; Participation (approx.)[C]: 73 million meals served.[H] HHS Administration on Aging: Program: Elderly Nutrition Program: Home-Delivered and Congregate Nutrition Services; Target population[A]: Elderly: Individuals 60 years of age and older and their spouses, especially those with the greatest social or economic need, and in certain cases, under age 60 if the individual is handicapped or disabled and accompanies an older individual to meals. Special focus is given to those with greatest economic or social need, including low-income minorities and those residing in rural areas; Benefit type[B]: Supports the provision of nutritious meals (with education and other services) served in a congregate setting or delivered to the home, if individual is homebound; Participation (approx.)[C]: More than 2.5 million seniors received home-delivered or congregate meals.[I] Program: Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services; Target population[A]: Elderly and special groups: American Indians, Alaska Natives, and Native Hawaiians who are at least 60 years old and their spouses (or those designated as "older Indian" by tribal authorities); Benefit type[B]: Grants are provided to tribal organizations to fund services including nutrition and supportive services, similar to those in the Elderly Nutrition Program: Home-Delivered and Congregate Nutrition Services; Participation (approx.)[C]: Approximately 70,000 American Indian elders received home-delivered or congregate meals in fiscal year 2007.[I] Source: GAO. [A] Information on target population is from the Catalog of Federal Domestic Assistance program profiles or agency program descriptions. While some programs specifically mention "families," rather than "households," in describing their target population, we elected to use the term "individuals and households" to refer to programs that provide assistance to general needy populations, rather than smaller targeted groups. [B] Information on benefit type is from the Catalog of Federal Domestic Assistance program profiles or agency program descriptions. [C] Unless otherwise indicated, program participation levels reflect fiscal year 2008 and reflect preliminary numbers reported in the USDA Program Information Report U.S. Summary, fiscal year 2008 to fiscal year 2009 (Food and Nutrition Service, USDA, June 2009). [D] The Community Food Projects Competitive Grants Program is administered by the National Institute of Food and Agriculture (formerly the Cooperative State Research, Education, and Extension Service, CSREES) of USDA. All other USDA programs listed above are administered by the Food and Nutrition Service. Community Food Projects Competitive Grants Program participation information is from CSREES Update: September17, 2009, Office of the Administrator, CSREES, USDA. [E] Fiscal year 2005 PART Assessment of Nutrition Assistance for Puerto Rico, (Office of Management and Budget). [F] Fiscal year 2010 Budget Summary and Annual Performance Plan USDA. [G] The Emergency Food Assistance Program: Total Food Cost 2005-2009, USDA, Food And Nutrition Service (Feb.1, 2010). [H] Fiscal year 2008 (phase 26) figure for meals served reported by Federal Emergency Management Agency to GAO from a database kept by the National Board Secretariat, based on reports from local agencies. [I] Investments in Change: Enhancing the Health and Independence of Older Americans, Administration on Aging (2008). [End of table] The 18 programs we studied vary by target population, size, types of benefits, and where these benefits are provided: * Target population. While the 18 programs serve four broad populations--individuals and households, children, the elderly, and special groups--the specific target populations vary across programs. For example, SNAP helps low-income individuals and families; the National School Lunch Program assists school-aged children; the Elderly Nutrition Program serves individuals 60 years of age and older; and WIC provides assistance to low-income, nutritionally at- risk children up to age 5 and pregnant and postpartum women. * Program size. The 18 programs also vary in size, ranging from the Food Distribution Program on Indian Reservations, which serves approximately 90,000 individuals per month, to SNAP, which serves more than 28 million people per month. * Benefit type. In addition, the programs differ by the types of benefits they provide. Some programs--such as SNAP--were designed to help low-income individuals and families obtain a nutritious diet by supplementing their income with cash-like benefits to purchase food, such as meat, dairy products, fruits, and vegetables, but not items such as certain hot foods, tobacco, or alcohol. Other programs provide food directly to program participants. The Emergency Food Assistance Program supplies large quantities of food to governmental or nonprofit organizations to prepare meals for or distribute food to individuals and families. The National School Lunch Program reimburses school districts for the meals served and provides some commodities from USDA to offset the cost of food service. Other programs do not directly provide benefits to individuals. For example, the Community Food Projects Competitive Grants Program provides grants to organizations to plan or implement projects to improve access to food for low-income individuals and families. * Program administration. USDA, DHS, and HHS fund all of the 18 programs through a decentralized service delivery structure of state and local agencies and nonprofit organizations. For example, WIC benefits are typically delivered through state agencies to state and county health departments; the Child and Adult Care Food Program works through state agencies to subsidize child care providers, day care homes, and adult day care facilities; and the Commodity Supplemental Food Program provides food to state agencies, which then distribute the food to local nonprofit organizations that provide it to recipients. Program Goals: Each federal food and nutrition assistance program has its own set of program goals that were generally established through legislation or regulation. These goals have a mix of underlying purposes, including: (1) raising the level of nutrition among low-income households, (2) safeguarding the health and wellbeing of the nation's children, (3) improving the health of Americans, and (4) strengthening the agricultural economy. (See appendix III for a summary of program goals.) While few have specific goals to reduce or alleviate hunger, most of these programs share an overarching goal of providing individuals access to a nutritionally adequate diet to ensure the health of vulnerable Americans.[Footnote 15] In addition, the current administration set a national goal to end childhood hunger in the United States by 2015 and the American Recovery and Reinvestment Act of 2009 (Recovery Act) expanded eligibility guidelines and increased benefits for SNAP, which may help the administration reach that goal. Nearly Fifteen Percent of U.S. Households Were Food Insecure Sometime in 2008, According to USDA: The prevalence of food insecurity (the percentage of households with low or very low food security) hovered between 10 and 12 percent from 1998 to 2007, before rising to 14.6 percent in 2008, according to USDA's analysis of CPS data.[Footnotes 16, 17] Following a similar pattern, very low food security stayed between 3 and just more than 4 percent from 1998 to 2007, and reached 5.7 percent in 2008. (See figure 1.) Figure 1: Trends in the Prevalence of Food Insecurity in U.S. Households from 1998 to 2008: [Refer to PDF for image: multiple line graph] Year: 1998; Households with very low food security: 3.7%; Households with low or very low food security: 11.8%. Year: 1999; Households with very low food security: 3.0%; Households with low or very low food security: 10.1%. Year: 2000; Households with very low food security: 3.1%; Households with low or very low food security: 10.5%. Year: 2001; Households with very low food security: 3.3%; Households with low or very low food security: 10.7%. Year: 2002; Households with very low food security: 3.5%; Households with low or very low food security: 11.1%. Year: 2003; Households with very low food security: 3.5%; Households with low or very low food security: 11.2%. Year: 2004; Households with very low food security: 3.9%; Households with low or very low food security: 12.0%. Year: 2005; Households with very low food security: 3.9%; Households with low or very low food security: 11%. Year: 2006; Households with very low food security: 4.0%; Households with low or very low food security: 10.9%. Year: 2007; Households with very low food security: 4.1%; Households with low or very low food security: 11.1%. Year: 2008; Households with very low food security: 5.7%; Households with low or very low food security: 14.6%. Source: Modified from a graph in Nord, Mark, Margaret Andrews, and Steven Carlson. Household Food Security in the United States, 2008. ERR-83, U.S. Department of Agriculture, Economic Research Service, November 2009. Note: The decline in food insecurity between 1998 and 1999 reflects, in part, a seasonal component to the data collection that affected food security rates between 1995 and 2000. This seasonal component can be more easily observed in the graph in appendix II, which presents the prevalence of food insecurity from 1995 to 2008. Food insecurity prevalence rates are sample-based estimates. For more information about the confidence intervals around the food insecurity rates, see appendix II. [End of figure] USDA recently reported that about 17 million households in the United States (or 14.6 percent of all U.S. households) were food insecure at some point in 2008. Of these food-insecure households, USDA reported that 6.7 million (or 5.7 percent of all U.S. households) had very low food security. (See figure 2.) This increase in food insecurity coincided with the recent economic recession, which began in late 2007 and continued throughout 2008. Figure 2: Food Insecurity among U.S. Households in 2008: [Refer to PDF for image: pie-chart] Food secure households: 85.4%; Food insecure households: 14.6%; - Households with low food security: 8.9%; - Households with very low food security: 5.7%. Source: Modified from a graph in Nord, Mark, Margaret Andrews, and Steven Carlson. Household Food Security in the United States,2008. ERR- 83, U.S. Department of Agriculture, Economic Research Service, November 2009. Note: Food insecurity prevalence rates are sample-based estimates. See appendix II for more information about the confidence intervals around the food insecurity rates. [End of figure] Among households with incomes below the poverty line, those headed by single parents, and those headed by minorities, prevalence rates for food insecurity were higher than the national average rate of 14.6 percent.[Footnote 18] (See figure 3.) According to USDA's analysis of the food security data, about 42 percent of households with incomes below the poverty line were food insecure in 2008.[Footnote 19] High levels of food insecurity were also found among single-parent households with children; for example, about 37 percent of households with children headed by single women were food insecure, and about 28 percent of households with children headed by single men were food insecure. In contrast, among married couples with children, 14.3 percent of households were food insecure. High levels of food insecurity were also found among households headed by minorities: for example, among households headed by Hispanics, nearly 27 percent were food insecure. Figure 3: Groups for Which Rates of Food Insecurity Were Higher Than the National Average in 2008: [Refer to PDF for image: stacked horizontal bar graph] Food insecurity (low and very low food security): All households: Low food security: 8.9%; Very low food security: 5.7%; Total: 14.6%. Households with incomes under the federal poverty line: Low food security: 23%; Very low food security: 19.3%; Total: 42.2%. Households with children headed by single mothers: Low food security: 23.8%; Very low food security: 13.3%; Total: 37.2%. Households with children headed by single fathers: Low food security: 20.5%; Very low food security: 7.2%; Total: 27.6%. Black, nonhispanic: Low food security: 15.6%; Very low food security: 10.1%; Total: 25.7%; Hispanic: Low food security: 18.1%; Very low food security: 8.8%; Total: 26.9%; Source: GAO using data from Nord, Mark, Margaret Andrews, and Steven Carlson. Household Food Security in the United States, 2008. ERR-83, U.S. Department of Agriculture, Economic Research Service, November 2009. Note: Food insecurity rates (the sum of low and very low food security rates) are shown in bold at the end of each bar. Low and very low food security rates may not sum exactly to food insecurity rates due to rounding. Hispanic households can be any race. Food insecurity prevalence rates are sample-based estimates. For more information about the confidence intervals around the food insecurity rates, see appendix II. [End of figure] Regardless of adults' marital status, the prevalence of food insecurity was almost twice as high among households with children (21 percent) as among households without children (11.3 percent). In many families--just under half of the roughly 8.3 million food-insecure households with children--parents were able to maintain normal or near- normal diets and meal schedules for their children, limiting the effects of food insecurity to only the adults. However, in more than 4.3 million of these households, children--as well as adults-- experienced food insecurity sometime during the year.[Footnote 20] Among households where children experienced food insecurity, most indicated low (but not very low) food security among children, reporting mainly reductions in the quality and variety of children's meals. Of the households with children just more than 1 percent (about 506,000 households) had very low food security among children--food insecurity that was so severe that children's eating patterns were disrupted and food intake was reduced below levels that caregivers considered sufficient. The Federal Government Spent More Than $62.5 Billion on 18 Food Assistance Programs in Fiscal Year 2008: Spending on the 18 Food Assistance Programs Totaled more than $62.5 Billion in Fiscal Year 2008: The federal government spent approximately $62.7 billion on 18 domestic food and nutrition assistance programs in fiscal year 2008, with the 5 largest programs accounting for 95 percent of total spending.[Footnote 21] Programs' spending amounts ranged from approximately $4 million on the Community Food Projects Competitive Grants Program to more than $37 billion on SNAP. (See table 3.) Spending on food assistance programs is often determined by both the value of the benefits and the number of program participants. In 2008, for example, approximately 28.4 million people (12.7 million households) participated in SNAP per month, with each individual receiving an average of about $101.50 per month. In contrast, approximately 2.2 million individuals participated in the WIC Farmers' Market Nutrition Program, with each participant receiving a benefit between $10 and $30 for the year. Table 3: Federal Spending on 18 Food and Nutrition Assistance Programs: Programs and funding streams: SNAP; Fiscal year 2008 spending in dollars (in millions): $37,645.4[A]. Programs and funding streams: National School Lunch Program; Fiscal year 2008 spending in dollars (in millions): $9,260.0. Programs and funding streams: WIC; Fiscal year 2008 spending in dollars (in millions): $6,382.2. Programs and funding streams: Child and Adult Care Food Program; Fiscal year 2008 spending in dollars (in millions): $2,394.1. Programs and funding streams: School Breakfast Program; Fiscal year 2008 spending in dollars (in millions): $2,355.8. Programs and funding streams: Nutrition Assistance for Puerto Rico; Fiscal year 2008 spending in dollars (in millions): $1,622.5. Programs and funding streams: Entitlement Commodity Obligations for Child Nutrition programs[B]; Fiscal year 2008 spending in dollars (in millions): $1,152.4. Programs and funding streams: Elderly Nutrition Program: Home- Delivered and Congregate Nutrition Services; Fiscal year 2008 spending in dollars (in millions): $745.0[C]. Programs and funding streams: Summer Food Service Program; Fiscal year 2008 spending in dollars (in millions): $324.1. Programs and funding streams: The Emergency Food Assistance Program; Fiscal year 2008 spending in dollars (in millions): $230.6[D]. Programs and funding streams: State Administrative Expenses for Child Nutrition[E]; Fiscal year 2008 spending in dollars (in millions): $146.3. Programs and funding streams: Emergency Food and Shelter National Board Program; Fiscal year 2008 spending in dollars (in millions): $140.1. Programs and funding streams: Commodity Supplemental Food Program; Fiscal year 2008 spending in dollars (in millions): $100.4. Programs and funding streams: Food Distribution Program on Indian Reservations; Fiscal year 2008 spending in dollars (in millions): $85.2. Programs and funding streams: Fresh Fruit and Vegetable Program; Fiscal year 2008 spending in dollars (in millions): $22.3[F]. Programs and funding streams: Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services; Fiscal year 2008 spending in dollars (in millions): $27.3[C]. Programs and funding streams: Senior Farmers' Market Nutrition Program; Fiscal year 2008 spending in dollars (in millions): $20.1. Programs and funding streams: Special Milk Program; Fiscal year 2008 spending in dollars (in millions): $14.8. Programs and funding streams: WIC Farmers' Market Nutrition Program; Fiscal year 2008 spending in dollars (in millions): $12.4. Programs and funding streams: Child Nutrition Discretionary Grants[E,G]; Fiscal year 2008 spending in dollars (in millions): $6.5. Programs and funding streams: Community Food Projects Competitive Grants Program; Fiscal year 2008 spending in dollars (in millions): v4.2[H]. Programs and funding streams: Total; Fiscal year 2008 spending in dollars (in millions): $62,691.7. Source: CFFR figures for fiscal year 2008, unless otherwise indicated. Note: CFFR spending amounts include state administrative costs for most programs and the value of USDA entitlement commodities for those programs that include commodity assistance (with the exception of child nutrition programs). Unless otherwise specified, funding amounts represent fiscal year 2008 obligations for USDA programs, annual reports of federal dollars spent by states in fiscal year 2008 as reported to the Administration on Aging for the Elderly Nutrition Program and the Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services (roughly equivalent to outlays). CFFR-reported spending amounts for the Federal Emergency Management Agency Emergency Food and Shelter National Board Program reflect outlays. [A] SNAP total amount includes Nutrition Assistance Programs for American Samoa and the Northern Mariana Islands, as well as funding for SNAP Outreach and Participation Grants and Food and Nutrition Service Disaster Assistance. [B] Entitlement Commodity Obligations for Child Nutrition programs provide commodity foods, or cash-in-lieu of commodities, to states for the provision of the National School Lunch Program, the Summer Food Service Program, and the Child and Adult Care Food Program. Because USDA does not have exact amounts for each of the three programs, we included this item throughout the table. [C] The Elderly Nutrition Program and Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services totals include the approximate share of Nutrition Services Incentive Program (NSIP) funds allocated to each of those programs, according to the Administration on Aging. (Total NSIP funding figures provided by the Administration on Aging and the Consolidated Federal Funds Report differ by approximately $60,000 out of $147 million.) [D] The spending amount for The Emergency Food Assistance Program includes a $50 million mid-year adjustment contained in the Food, Conservation, and Energy Act of 2008 (the 2008 Farm Bill), based on information from USDA Food and Nutrition Service budget officials. [E] The State Administrative Expenses for Child Nutrition and Child Nutrition Discretionary Grants are not included as separate programs in this analysis. However, these funding streams support administrative expenses and special projects across USDA's five child nutrition programs: National School Lunch Program, School Breakfast Program, Special Milk Program, Summer Food Service Program, and Child and Adult Care Food Program. As USDA is not able to separate the state- level spending across the five programs, the two spending amounts are listed whole in this table. [F] Funding for the Fresh Fruit and Vegetable Program is not included in the Consolidated Federal Funds Report. Spending amount provided by USDA budget officials. [G] Amount of spending on Child Nutrition Discretionary Grants was not included in the Consolidated Federal Funds Report. Spending amount provided by USDA Food and Nutrition Service budget officials. [H] According to USDA, the Community Food Projects Competitive Grants Program did not receive any appropriations in fiscal year 2008; however, this total represents in fiscal year 2008 outlays for the program carried over from earlier grants (program grants are awarded to grantees for 1 to 3 years). Data was provided by USDA budget officials. [End of table] In fiscal year 2008, the five largest food assistance programs--SNAP, the National School Lunch Program, WIC, the Child and Adult Care Food Program, and the School Breakfast Program--accounted for 95 percent of total spending on the 18 programs. SNAP, the largest program, accounted for more than 60 percent of the overall spending total. (See figure 4.) Compared to the other 13 programs, the largest five food assistance programs have relatively high numbers of participants, and all but WIC are entitlement programs--meaning that, by law, they must provide benefits to all individuals or households that meet eligibility requirements and apply for the program.[Footnote 22] This means that participation and benefits for these programs are not capped, unlike programs that are appropriated specific spending amounts, such as the Commodity Supplemental Food Program or the Elderly Nutrition Program. Figure 4: Percentage of Food Assistance Spending by Program in Fiscal Year 2008: [Refer to PDF for image: pie-chart] SNAP: 61%; National School Lunch Program: 15%; WIC: 10%; School Breakfast Program: 4%; Child and Adult Care Food Program: 4%; All Other Programs: 5%. Source: GAO presentation of Consolidated Federal Funds Report data and additional spending data reported by agency officials. Note: Due to rounding, percentages do not add up to 100 percent. Spending amounts do not include entitlement commodity obligations for Child Nutrition Programs, State Administrative Expenses for Child Nutrition Programs, or Child Nutrition Discretionary Grants, as each funds multiple programs. [End of figure] Spending on Most of the Large Programs--Excluding SNAP--Has Remained Stable: Since 1995 SNAP spending has fluctuated, while spending on the other large programs--the National School Lunch Program, WIC, the School Breakfast Program, and the Child and Adult Care Food Program--remained relatively stable. Between 1995 and 2000 the amount the federal government spent on SNAP declined by 37.4 percent from $34.9 billion to $21.8 billion.[Footnote 23] However, between fiscal years 2001 and 2007, SNAP spending rose to $34.5 billion, nearly matching its previous 1995 level. In fiscal year 2008, spending on SNAP totaled $37.6 billion--a sharp increase of 9 percent in one year. In contrast, spending on the other large programs was relatively stable from 1995 through 2000, and most increased slightly between 2001 and 2008; [Footnote 24] however, WIC had an increase of 11 percent between 2007 and 2008. Overall, when adjusted for inflation the federal government spent 14 percent more on the largest five programs in fiscal year 2008 than it did on those five programs in fiscal year 1995.[Footnote 25] (See figure 5.) Figure 5: Spending on the Five Largest Programs from 1995 to 2008, Adjusted to 2008 Dollars (dollars in billions): [Refer to PDF for image: multiple line graph] Year: 1995; Child and Adult Care Food Program: $2,115; WIC: $4,974; National School Lunch Program: $7,288; School Breakfast Program: $1,669; SNAP: $34,873. Year: 1996; Child and Adult Care Food Program: $2,145; WIC: $4,991; National School Lunch Program: $7,258; School Breakfast Program: $1,346; SNAP: $33,439. Year: 1997; Child and Adult Care Food Program: $2,088; WIC: $4,959; National School Lunch Program: $7,421; School Breakfast Program: $1,601; SNAP: $28,909. Year: 1998; Child and Adult Care Food Program: $2,250; WIC: $5,109; National School Lunch Program: $7,578; School Breakfast Program: $1,746; SNAP: $25,259. Year: 1999; Child and Adult Care Food Program: $2,267; WIC: $5,462; National School Lunch Program: $8,063; School Breakfast Program: $1,825; SNAP: $23,744. Year: 2000; Child and Adult Care Food Program: $366; WIC: $4,949; National School Lunch Program: $7,677; School Breakfast Program: $1,742; SNAP: $21,831. Year: 2001; Child and Adult Care Food Program: $323; WIC: $5,026; National School Lunch Program: $7,863; School Breakfast Program: $1,757; SNAP: $21,661. Year: 2002; Child and Adult Care Food Program: $2,216; WIC: $5,192; National School Lunch Program: $8,098; School Breakfast Program: $1,876; SNAP: $24,658. Year: 2003; Child and Adult Care Food Program: $2,253; WIC: $5,295; National School Lunch Program: $8,233; School Breakfast Program: $1,932; SNAP: $27,866. Year: 2004; Child and Adult Care Food Program: $2,303; WIC: $5,689; National School Lunch Program: $8,457; School Breakfast Program: $2,023; SNAP: $31,040. Year: 2005; Child and Adult Care Food Program: $2,344; WIC: $5,707; National School Lunch Program: $8,678; School Breakfast Program: $2,125; SNAP: $34,427. Year: 2006; Child and Adult Care Food Program: $2,300; WIC: $5,700; National School Lunch Program: $8,709; School Breakfast Program: $2,181; SNAP: $35,222. Year: 2007; Child and Adult Care Food Program: $2,325; WIC: $5,746; National School Lunch Program: $9,053; School Breakfast Program: $2,246; SNAP: $34,522. Year: 2008; Child and Adult Care Food Program: $2,394; WIC: $6,382; National School Lunch Program: $9,260; School Breakfast Program: $2,356; SNAP: $37,638. Source: GAO analysis of Consolidated Federal Funds Report data. Note: Spending amounts do not include entitlement commodity obligations for Child Nutrition Programs, State Administrative Expenses for Child Nutrition Programs, or Child Nutrition Discretionary Grants, as each of those funding streams funds multiple programs. Additionally, SNAP spending does not include two amounts that were reflected in table 3--SNAP Outreach and Participation Grants and Disaster Assistance--due to lack of historical spending data from the Consolidated Federal Funds Report. [End of figure] Economic conditions--such as unemployment or poverty--affect spending on food assistance programs. Because the five largest programs serve all or nearly all eligible individuals who apply, increases in poverty that occur during economic downturns can lead to increases in program participation, and consequently, increases in program spending. Of the five large programs, SNAP, which serves the largest population, is particularly responsive to economic changes. For example, changes in SNAP spending between 1995 and 2008 generally tracked the percentage of people who were unemployed, and spending changes were significantly correlated with the percentage of people living in poverty during those times (see figure 6).[Footnote 26] Consequently, the recent economic recession contributed to the demand for and spending on SNAP. USDA reported that SNAP participation nationwide increased in almost every month between December 2007, when the recession began, and September 2009, the last month for which information is available. Between June 2008 and 2009, SNAP participation increased by just over 22 percent nationwide. Spending on SNAP during the same time period increased by nearly 49 percent, due in part to increases in both participation and benefit rates.[Footnote 27] Congress anticipates a continued expansion in SNAP spending: USDA's 2010 appropriation includes approximately $58.3 billion for SNAP, a 55 percent increase compared to fiscal year 2008 spending. Figure 6: Spending on SNAP, with Federal Poverty and Unemployment Rates, Fiscal Years 1995 to 2008: [Refer to PDF for image: multiple line graph] Year: 1995 SNAP Expenditures: $34.9 billion; Poverty rate: 13.8%. Unemployment rate: 5.6%. Year: 1996 SNAP Expenditures: $33.4 billion; Poverty rate: 13.7%. Unemployment rate: 5.4%. Year: 1997 SNAP Expenditures: $28.9 billion; Poverty rate: 13.3%. Unemployment rate: 4.9%. Year: 1998 SNAP Expenditures: $25.3 billion; Poverty rate: 12.7%. Unemployment rate: 4.5%. Year: 1999 SNAP Expenditures: $23.7 billion; Poverty rate: 11.9%. Unemployment rate: 4.2%. Year: 2000 SNAP Expenditures: $21.8 billion; Poverty rate: 11.3%. Unemployment rate: 4%. Year: 2001 SNAP Expenditures: $21.7 billion; Poverty rate: 11.7%. Unemployment rate: 4.7%. Year: 2002 SNAP Expenditures: $24.7 billion; Poverty rate: 12.1%. Unemployment rate: 5.8%. Year: 2003 SNAP Expenditures: $27.9 billion; Poverty rate: 12.5%. Unemployment rate: 6%. Year: 2004 SNAP Expenditures: $31 billion; Poverty rate: 12.7%. Unemployment rate: 5.5%. Year: 2005 SNAP Expenditures: $34.4 billion; Poverty rate: 12.6%. Unemployment rate: 5.1%. Year: 2006 SNAP Expenditures: $35.2 billion; Poverty rate: 12.3%. Unemployment rate: 4.6%. Year: 2007 SNAP Expenditures: $34.5 billion; Poverty rate: 12.5%. Unemployment rate: 4.6%. Year: 2008 SNAP Expenditures: $37.6 billion; Poverty rate: 13.2%. Unemployment rate: 5.8%. Source: GAO analysis of program expenditure data from the Consolidated Federal Funds Report, poverty rate data from the U.S. Census Bureau, Current Population Survey, 1996 to 2009 Annual Social and Economic Supplements, and unemployment rate data from the U.S. Bureau of Labor Statistics, Department of Labor, Current Population Survey annual averages. Note: Between fiscal years 2003 and 2005, spending on SNAP diverged from poverty and unemployment trends, due partly to federal efforts (beginning in 2001) to expand SNAP outreach and participation among eligible households. These efforts--which included outreach and participation grants provided to state and local governments and universities, as well as nonprofit organizations--were intended to simplify state SNAP eligibility and application processes, and to improve access to SNAP for eligible applicants. [End of figure] State officials and local providers we spoke with also reported significant increases in the demand for federal food assistance during challenging economic conditions, and some found the recent influx of federal funds crucial in meeting that demand. Oregon state officials told us in June 2009 that SNAP applications statewide had increased by more than 40 percent during the previous year. Also, food bank officials in Texas told us that in June 2008 demand for services at their member food banks--supported by The Emergency Food Assistance Program--increased by 30 percent in the previous year. According to these officials, the additional funding that the program received from the Food, Conservation, and Energy Act of 2008 (2008 Farm Bill) [Footnote 28] and the Recovery Act[Footnote 29] was critical in keeping up with this demand. The Recovery Act alone provided more than $21 billion for food assistance programs. These funds included a USDA estimated $20.1 billion for SNAP, in the form of increased benefits and state administrative expenses; $500 million for WIC; $100 million for equipment assistance for child nutrition programs; $150 million for The Emergency Food Assistance Program; $100 million for the Emergency Food and Shelter National Board Program; and $100 million for the Elderly Nutrition Program and Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services.[Footnote 30] In addition to economic conditions, other factors--such as natural disasters, food costs, and outreach--can affect changes in program spending over time. According to USDA, SNAP showed an increase in spending in the fall of 2005 because of the additional assistance this program provided to hurricane victims mostly in the Gulf Coast states. Similarly, USDA attributed some of the increase in SNAP participation during 2008 to the effects of Hurricane Gustav. Rising food costs can be another driver of increased spending on some federal food assistance programs, particularly for the WIC program, which provides specific foods to women and their infants and young children. USDA's Economic Research Service reported an increase of 12 percent in per person food costs for WIC between fiscal years 2007 and 2008, noting rising food costs as a major factor in increased WIC spending during that time. SNAP and the National School Lunch Program also make periodic adjustments in their benefit or reimbursement amounts based on the cost of food.[Footnote 31] Also, federal efforts beginning in 2001 to expand the proportion of eligible households participating in SNAP likely contributed to increases in participation and spending. These efforts included simplifying state SNAP eligibility and application processes and improving access to SNAP for eligible applicants. Research Shows 7 Programs Have Positive Outcomes Related to Their Goals but Little Is Known about the Remaining 11 Programs: Seven Programs--Including Four of the Five Largest--Generally Show Positive Outcomes Consistent with Many of Their Program Goals: Research suggests that participation in seven of the programs we reviewed, including four of the five largest--WIC, the National School Lunch Program, the School Breakfast Program, and SNAP--is associated with positive health and nutrition outcomes consistent with most of these programs' goals, including raising the level of nutrition among low-income households, safeguarding the health and wellbeing of the nation's children, improving the health of Americans, and strengthening the agricultural economy (see appendix III for summary of program goals).[Footnote 32] [Side bar: WIC Program Goals: * Improve the mental and physical health of low-income pregnant, postpartum, and breastfeeding women, infants, and young children. * Prevent the occurrence of health problems, including drug abuse, and improve the health status of the target population. * Provide supplemental foods and nutrition education to target population. End of side bar] WIC. Research generally suggests that participation in the WIC program is associated with positive outcomes related to all three of its program goals.[Footnote 33] For example, studies indicate that WIC has had several positive effects related to its goal of improving the mental and physical health of low-income pregnant, postpartum, and breastfeeding women, infants, and young children. Specifically, research suggests that WIC has some positive effects on individual dietary and nutrient intake,[Footnote 34] mean birth weight,[Footnote 35] general health status of infants and children, and the likelihood that children will receive complete and timely immunization, among other outcomes. One study also found that WIC participation was associated with reduced rates of child abuse and neglect. With regard to WIC's goal of preventing the occurrence of health problems and improving the health status of the target population, some research suggests that WIC reduces anemia and other nutritional deficiencies, improves the diet quality and food use of households, and may even slightly increase the rates at which pregnant women quit smoking. [Footnote 36] Research on some of the other outcomes related to WIC's goals is less conclusive. For example, findings are mixed on whether participation in the program increases the initiation or duration of breastfeeding or improves cognitive development and behavior of participants--outcomes that are related to WIC's goals of improving the mental and physical health of recipients and preventing the occurrence of health problems and improving the health status of recipients. [Side bar: National School Lunch Program Goals: * Safeguard the health and wellbeing of the nation’s children. * Encourage the domestic consumption of nutritious agricultural commodities and other foods. School Breakfast Program Goals: * Safeguard the health and wellbeing of the nation's children. * Encourage the domestic consumption of agricultural and other foods by assisting states to more effectively meet the nutritional needs of children. * Assist the states and Department of Defense to initiate, maintain, or expand nonprofit breakfast programs in all schools that apply for assistance and agree to carry out a nonprofit breakfast program. End of side bar] The National School Lunch and School Breakfast programs. Research suggests that both the National School Lunch and the School Breakfast programs have had some positive effects on health and nutrition outcomes related to their goals of (1) safeguarding the health and wellbeing of children and (2) encouraging the domestic consumption of agricultural and other foods.[Footnote 37] Related to the goal of safeguarding the health and wellbeing of children, research shows that both programs increase the dietary and nutrient intakes of participating students. For example, research finds that the School Breakfast Program improves students' scores on a Healthy Eating Index [Footnote 38] and reduces the probability that students will have low fiber, iron, and potassium intake and low serum levels of vitamins C and E and folate. Also, research suggests that the National School Lunch Program increases the frequency of eating lunch among participants. However, research produced conflicting results on the School Breakfast Program's effects on other outcomes related to this goal, such as whether the program increases the frequency that students eat breakfast. An evaluation of the School Breakfast Pilot Program, which unlike the traditional School Breakfast Program, provided universal free meals, found no effect on general measures of health or cognitive development.[Footnote 39] The same study examining the School Breakfast Pilot Program found that the program had a small negative effect on student behavior (as rated by teachers). Similarly, there is conflicting and inconclusive evidence on the National School Lunch Program's effects on other outcomes related to the goal of safeguarding the health and wellbeing of children, such as childhood obesity.[Footnote 40] In addition, research finds that the National School Lunch Program has no effect on children's cognitive development or behavior or iron status. Related to their other similar goal, some evidence suggests that the School Breakfast and the National School Lunch programs encourage the domestic consumption of agricultural and other foods.[Footnote 41] A 2003 report by USDA's Economic Research Service found that through additional food consumption, school nutrition programs[Footnote 42]--of which the National School Lunch and School Breakfast programs are the largest--increased food expenditures by an additional $1.9 billion,[Footnote 43] increased farm production by just more than $1 billion, increased labor earnings and returns to farm ownership by $318 million, and supported approximately an additional 9,200 farm jobs.[Footnote 44] [Side bar: SNAP Goals: * Raise the level of nutrition among low-income households. * Alleviate hunger and malnutrition in low-income households. * Increase food purchasing power for eligible households. * Strengthen the U.S. agricultural sector. * More orderly marketing and distribution of food. * Permit low-income households to obtain a more nutritious diet through normal channels of trade. End of side bar] SNAP. Literature also suggests that participation in SNAP, the largest of the federal food and nutrition programs, is associated with positive effects on outcomes related to many of its goals. According to the research, participation in SNAP has several positive outcomes related to the program's goals of raising the level of nutrition and increasing the food purchasing power of low-income households. For example, participation in SNAP has been found to increase household food expenditures,[Footnote 45] increase the availability of nutrients to the household, and, as some research has found, reduce anemia and other nutritional deficiencies. In addition, increasing household food expenditures is also related to SNAP's goal of strengthening the U.S. agricultural economy. However, the literature is inconclusive regarding whether SNAP alleviates hunger and malnutrition in low- income households, another program goal. While studies show the program increases household food expenditures and the nutrients available to the household, research finds little or no effect on the dietary or nutrient intake of individuals. The Economic Research Service cites several reasons why, despite increasing household nutrient availability, SNAP may not affect individual dietary and nutrient intakes. For example, all household members might not share equally in the consumption of additional nutrients made available by SNAP benefits, some food may be wasted or consumed by guests, and some household members might consume food from other "nonhome" sources. In addition, the availability of more food in the house does not guarantee individuals eat a healthier diet. [Side bar: Elderly Nutrition Program: Home Delivered and Congregate Nutrition Services Goals: * Reduce hunger and food insecurity. * Promote socialization of older individuals. * Promote the health and wellbeing of older individuals by assisting such individuals to gain access to nutrition and other disease prevention and health promotion services to delay the onset of adverse health conditions resulting from poor nutritional health or sedentary behavior. Nutrition Assistance for Puerto Rico Goals: * Fund nutrition assistance programs for needy people. Special Milk Program Goals: * Encourage consumption of fluid milk by U.S. children in nonprofit schools high school grade and under that don't participate in federal meal service programs. * Encourage consumption of fluid milk by U.S. children in nonprofit institutions devoted to the care and training of children, such as nursery schools and child care centers, that don't participate in federal meal service programs. * Safeguard the health and well-being of the nation's children. * Encourage the domestic consumption of agricultural and other foods by assisting states to more effectively meet the nutritional needs of children. End of side bar] Additional programs. The literature also suggests that participation in three of the smaller programs--the Elderly Nutrition Program: Home Delivered and Congregate Nutrition Services; Nutrition Assistance for Puerto Rico; and the Special Milk Program--is associated with positive outcomes related to their program goals. The research on the Elderly Nutrition Program: Home Delivered and Congregate Nutrition Services directly addresses two of the program's goals. Studies found that the program increases socialization[Footnote 46] and may have a positive effect on food security.[Footnote 47] In addition, research suggests the program improves participants' dietary and nutrient intake--an outcome related to the program's goal of promoting the health and wellbeing of older individuals by assisting such individuals to gain access to nutrition and other disease prevention and health promotion services to delay the onset of adverse health conditions resulting from poor nutritional health or sedentary behavior. However, the research does not provide enough evidence to assess the program's effects on other goal-related outcomes, such as nutritional status. Research on the Nutrition Assistance for Puerto Rico and the Special Milk Program is somewhat limited and dated. However, studies on Nutrition Assistance for Puerto Rico suggests that participation in the program increases household access to a variety of nutrients--an outcome related to its goal of funding nutrition assistance programs for needy people. Research also shows that participation in the Special Milk Program has positive effects, including increasing children's intake of vitamins and minerals found in milk. In addition to the programs' individual goals, USDA has a broad outcome measure to reduce and prevent hunger by improving access to federal nutrition programs but studies show that programs' effectiveness in achieving this outcome are mixed. Some research found that the National School Lunch Program has a positive effect on the food security status of families with children who participate in the program. For example, one study[Footnote 48] found that for households with children that experienced hunger during the previous year, those that participated in the National School Lunch Program were more likely to be food secure during the month before they were surveyed than those that didn't participate. Some studies also found that SNAP positively impacts food security. A recent paper[Footnote 49] released by USDA's Economic Research Service found that households' food security deteriorated during the seven to eight months before entering SNAP and improved after the households' began receiving SNAP benefits, suggesting that SNAP reduced the prevalence of very low food security. [Footnote 50] A second study found that while simply participating in SNAP did not reduce the odds of being food insecure, the level of benefits received did--every additional $10 in SNAP benefits was associated with a 12 percent reduction in the odds of a household being food insecure.[Footnote 51] However, other research findings differ on whether SNAP and other programs increase food security. For example, one study found that food security more often worsened than improved for households that began receiving SNAP benefits in 2001 and 2002 and conversely, as households left the program, their food security status more often improved than worsened.[Footnote 52] Similarly, research is not conclusive regarding WIC's success in increasing food security for participants,[Footnote 53] and research did not produce clear results on whether the School Breakfast Program improved participants' food security.[Footnote 54] According to USDA and academic researchers, there are several reasons why participation in food assistance programs may not be clearly associated with improvements in food security. While some programs focus more on improving or safeguarding the health of participants, the approaches used by these programs may not be as effective in reducing food insecurity. For example, the WIC program provides a relatively small, but highly targeted, food package consisting of high nutrient foods to address common nutritional deficiencies, an approach that may have only a small impact on the food security of recipients. Other programs may improve food security, but their impact may be difficult to measure because economic trends--such as changes in poverty and unemployment rates and changes in other assistance received by households--also affect food security. In addition, those who choose to participate in food assistance programs generally have greater difficulty meeting their food needs and tend to be more food insecure compared to others that are eligible for programs but do not participate. Little Is Known about the Health and Nutrition Outcomes of the Remaining 11 Programs: Little is known about the effectiveness of the remaining 11 programs because they have not been well studied. We found only one study that measured the impact of the Summer Food Services Program on outcomes related to its goals. Similarly, only one study of the Child and Adult Care Food Program compared facilities that participate in the program with those that did not. While these studies had generally positive results, more research would be needed to draw conclusions about the outcomes of the programs they studied.[Footnotes 55, 56] For other programs, no academic literature was identified that addressed outcomes related to their goals. For example, only one study we reviewed evaluated the effects of the Commodity Supplemental Food Program, but the findings from this study were not directly related to the program's goal of providing food to help meet the nutritional needs of the target population. [Footnote 57] Table 4 summarizes the level of research we found on each program. Table 4: Amount of Research Identified on Programs: Program: Child and Adult Care Food Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: Commodity Supplemental Food Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: Community Food Projects Competitive Grant Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: Elderly Nutrition Program: Home Delivered and Congregate Nutrition Services; Research identified program outcomes related to goals[A]: [Check]; Too little research available to identify outcomes[B]: [Empty]. Program: Emergency Food and Shelter National Board Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: Food Distribution Program on Indian Reservations; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: Fresh Fruit and Vegetable Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: Nutrition Assistance for Puerto Rico; Research identified program outcomes related to goals[A]: [Check]; Too little research available to identify outcomes[B]: [Empty]. Program: National School Lunch Program; Research identified program outcomes related to goals[A]: [Check]; Too little research available to identify outcomes[B]: [Empty]. Program: School Breakfast Program; Research identified program outcomes related to goals[A]: [Check]; Too little research available to identify outcomes[B]: [Empty]. Program: Seniors Farmers' Market Nutrition Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: SNAP; Research identified program outcomes related to goals[A]: [Check]; Too little research available to identify outcomes[B]: [Empty]. Program: Special Milk Program; Research identified program outcomes related to goals[A]: [Check]; Too little research available to identify outcomes[B]: [Empty]. Program: Summer Food Service Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: The Emergency Food Assistance Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Program: WIC; Research identified program outcomes related to goals[A]: [Check]; Too little research available to identify outcomes[B]: [Empty]. Program: WIC Farmers' Market Nutrition Program; Research identified program outcomes related to goals[A]: [Empty]; Too little research available to identify outcomes[B]: [Check]. Source: GAO. [A] At least two studies were identified which addressed program effects on health, nutrition, or other outcomes related to program goals. [B] Less than two studies were identified, or the research that was identified did not address program effects related to program goals, was methodologically weak or flawed, or was too conflicting to allow for assessments of program effects. [End of table] One government evaluation--the Program Assessment Rating Tool (PART) developed by the Office of Management and Budget--provides some additional information on the effectiveness of 7 of the 11 less studied programs.[Footnote 58] Four of these seven programs--the WIC Farmers' Market Nutrition Program, the Seniors Farmers' Market Nutrition Program, The Emergency Food Assistance Program, and the Commodity Supplemental Food Program--received ratings of "results not demonstrated." The Summer Food Service Program was rated as "moderately effective." Both the Child and Adult Care Food Program and the Food Distribution Program on Indian Reservations received ratings of "adequate." The other four programs for which limited academic research was identified have not been evaluated.[Footnote 59] (See table 5.) It is important to note that PART rates programs on their purpose and design, strategic planning, program management, and program results and accountability rather than looking at specific outcomes as the academic literature generally does. Therefore, PART's ratings do not provide the same type of assessment of program effectiveness as, and are not directly comparable to, the findings from academic research. Table 5: Summary of Program Assessment Rating Tool (PART) Evaluations of the 11 Less Researched Programs: Program: Summer Food Service Program; PART evaluation rating: Moderately effective; Year evaluated: 2006. Program: Child and Adult Care Food Program; PART evaluation rating: Adequate; Year evaluated: 2006. Program: Food Distribution Program on Indian Reservations; PART evaluation rating: Adequate; Year evaluated: 2006. Program: Seniors Farmers' Market Nutrition Program; PART evaluation rating: Results not demonstrated; Year evaluated: 2006. Program: WIC Farmers' Market Nutrition Program; PART evaluation rating: Results not demonstrated; Year evaluated: 2006. Program: The Emergency Food Assistance Program; PART evaluation rating: Results not demonstrated; Year evaluated: 2005. Program: Commodity Supplemental Food Program; PART evaluation rating: Results not demonstrated; Year evaluated: 2004. Program: Community Food Projects Competitive Grant Program; PART evaluation rating: Not evaluated; Year evaluated: n/a. Program: Emergency Food and Shelter National Board Program; PART evaluation rating: Not evaluated; Year evaluated: n/a. Program: Fresh Fruit and Vegetable Program; PART evaluation rating: Not evaluated; Year evaluated: n/a. Program: Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services[A]; PART evaluation rating: Not evaluated; Year evaluated: n/a. Source: GAO presentation of data from [hyperlink, http://www.whitehouse.gov/omb/performance/]. [A] PART evaluated the entire Administration on Aging in 2007 and rated it "effective" but did not evaluate its food and nutrition assistance programs separately. [End of table] Additionally, agency data show that the 11 less-studied programs provide food and nutrition assistance to millions of individuals and households each year--an outcome related to their goals--however, this alone does not demonstrate the overall effectiveness of these programs. One of the goals of the Summer Food Service Program is to provide food to children from needy areas during periods when schools are closed. USDA data show that this program served an average of more than 2.1 million children a day during July of 2008 and provided almost 130 million meals to children during the course of that fiscal year. In addition, a goal of the Child and Adult Care Food Program is to enable nonresidential institutions to provide nutritious food service to program participants. According to USDA, approximately 3.1 million children[Footnote 60] received free meals or snacks each day in fiscal year 2008 in child care centers or day care homes through this program. Smaller programs also provide benefits to millions of individuals and households. For example, in fiscal year 2008, the WIC Farmers' Market Nutrition Program provided coupons to assist about 2.2 million participants purchase fresh produce--an outcome related to the program's goal of providing fresh nutritious unprepared foods from farmers' markets to women, infants, and children at nutritional risk. In that same year, The Emergency Food Assistance Program distributed approximately 337 million pounds of food to hunger relief organizations, such as food banks and soup kitchens, and the Federal Emergency Management Agency's Emergency Food and Shelter National Board Program served more than 73 million meals to needy individuals and families. Both of these programs have goals related to providing food assistance to needy individuals through eligible organizations. Although these programs provide food to their target populations, this alone is too little information to assess the overall effectiveness of these programs. The System of Multiple Programs and Agencies That Provide Food Assistance Helps Address a Variety of Needs but Can Result in Overlap and Inefficiency: The 18 Food Assistance Programs Are Designed to Meet a Variety of Needs: Federal food assistance is provided through a decentralized system that involves multiple federal, state, and local providers and covers 18 different programs. Three federal agencies, numerous state government agencies, as well as many different types of local providers--including county government agencies and private nonprofit organizations--play a role in providing federal food assistance, but the decentralized network of federal, state, and local entities can be complex. Figure 8 illustrates how the federal food assistance programs are administered through a decentralized network of state offices and local providers in Texas--an organizational structure we found less complicated than some of the other states we visited. Figure 7: Entities That Administer Federal Food Assistance Programs in Texas: [Refer to PDF for image: organization chart] Department of Agriculture: WIC: WIC Farmer's Market: * Texas Department of State Health Services; * Regional and local WIC offices; - Children. SNAP: * Texas Health and Human Services Commission (HHSC); * Local HHSC offices; - Individuals and households. The Emergency Food Assistance Program: National School Lunch Program: Special Milk Program: Child and Adult Care Food Program: Summer Food Service Program: Fresh Fruit and Vegetable Program: Senior Farmers’Market Nutrition Program: Commodity Supplemental Food Program: * Texas Department Agriculture: Schools; Camps, youth programs; Children; Child/adult day care institutions; Special groups; * Local education agencies: Camps, youth programs; Children; * Food banks: Farmer's markets; Soup kitchens; Food pantries; Child/adult day care institutions; Special groups. Department of Homeland Security--FEMA: Emergency Food and Shelter National Board Program: * Local boards; - food banks; - food pantries. HHS--Administration on Aging: Grants to American Indian, Alaska Native and Native Hawaiian Organizations for Nutrition and Supportive Services: * Tribal organizations; - Individuals and households. Elderly Nutrition Program: Home-Delivered and Congregate Nutrition Services: * Texas Department of Aging and Disability Services; * Area agencies on aging; - Elderly. Source: GAO analysis of information gathered from interviews with state officials and local providers in Texas. Note: The figure provides an illustration of the major pathways by which benefits from federal food assistance programs reach recipients in Texas, and some categories have been simplified for ease of illustration. [End of figure] The federal response to food insecurity and the decentralized network of programs developed to address it emerged piecemeal over many decades to meet a variety of needs. For example, according to the USDA, an early food stamp program created during the Great Depression was designed to help relieve agricultural surpluses by providing food to needy individuals and households. This early food stamp program, like SNAP, was generally available to most needy households with limited income and assets[Footnote 61] and not targeted to a specific subgroup, but also like SNAP, it was not intended to meet a household's full nutritional needs. Over time, when it became evident that despite the availability of food stamps, certain vulnerable populations continued to experience nutritional risk, additional programs were developed to meet those needs. The origin of WIC, for example, dates back to the 1960s when a White House Conference on Food, Nutrition, and Health recommended that special attention be given to the nutritional needs of low-income pregnant women and preschool children based on the premise that early nutrition intervention can improve the health of children and prevent health problems later in life. The Emergency Food Assistance Program-- authorized in 1983--was created to utilize excess federal food inventories and assist states with storage costs while assisting the needy, while the Emergency Food and Shelter National Board Program-- administered by Federal Emergency Management Agency--was established in the 1980s to provide assistance to the homeless. By targeting various needs, the 18 food assistance programs help increase access to food for vulnerable populations, according to several agency officials and local providers we spoke with. Some officials and providers told us that individuals in need of food assistance have different comfort levels with different types of assistance and delivery mechanisms and the diversity of food assistance programs can help ensure that low-income individuals and households who need assistance have access to at least one program. For example, some individuals in need of assistance prefer to pick up a bag of groceries from a food bank rather than having to complete the application and eligibility procedures necessary to receive SNAP benefits. Others, such as those in rural areas, may find it easier to receive food assistance through commodities from the Commodity Supplemental Food Program or other programs, as a lack of local grocery stores can make it difficult to use SNAP benefits. Several officials said that the availability of multiple programs provided at different locations within a community can also increase the likelihood that eligible individuals seeking benefits from one program will be referred to other appropriate programs. In addition, several officials and providers told us that since no one program alone is intended to meet a household's full nutritional needs, the variety of food assistance programs offers eligible individuals and households different types of assistance and can help households fill the gaps and address the specific needs of individual members. For example, a single parent with a low-paying job may rely on SNAP for her basic groceries, the National School Lunch Program to feed her child at school, and WIC to provide high-nutrient supplemental foods for herself and her infant. While the federal government's food assistance structure allows households to receive assistance from more than one program at a time, USDA data indicate that a small portion of food insecure households received assistance from more than one of the primary food assistance programs. According to USDA, of the food insecure, low-income households, only about 3 percent participated in all of the three largest programs--SNAP, the National School Lunch Program, and WIC. [Footnote 62] Additionally, 12 percent participated in both SNAP and the National School Lunch program, about 15 percent participated in only SNAP, and another 15 percent participated in only the National School Lunch Program (see figure 7). USDA reported that some food insecure households also received other types of food assistance, such as through food pantries and soup kitchens. Figure 8: Program Participation of Low-Income Households with Low or Very Low Food Security, 2007-2008: [Refer to PDF for image: pie-chart] No program participation: 45%; Any program participation: 55%. * Of this 55%: - 15%: SNAP only; - 3% SNAP, WIC; - 3%; SNAP, NSLP, and WIC; - 12%: SNAP, NSLP. - 3%: NSLP, WIC; - 15%: NSLP only; - 4%: WIC only; SNAP total: 33%; NSLP total: 33%. Source: GAO presentation of unofficial special tabulations provided by the Economic Research Service, USDA, using data from December 2007 and December 2008 Current Population Survey Food Security Supplements. Note: Low-income households have an annual household income less than 185 percent of the poverty line. Both food insecurity and program participation were measured over the 30 days prior to the food security surveys in mid-December. [End of figure] The Multiple Food Assistance Programs Show Signs of Program Overlap, Which Can Result in Inefficient Use of Resources, and USDA Has Taken Some Steps to Address This: The federal food assistance structure--with its 18 programs--shows signs of program overlap, which can create unnecessary work and waste administrative resources, creating inefficiency. Program overlap occurs when multiple programs have comparable benefits going to similar target populations--not uncommon within programs that are administered by multiple agencies and local providers. GAO's previous work has shown that overlap among programs can create an environment in which participants are not served as efficiently and effectively as possible.[Footnote 63] Additionally, program overlap can create the potential for unnecessary duplication of efforts for administering agencies, local providers, and individuals seeking assistance. [Footnote 64] Such duplication can waste administrative resources and confuse those seeking services. During our site visits, we found ways in which overlap among the 18 food assistance programs may be creating unnecessary work for providers and applicants and may be using more administrative resources than needed. The following examples came from selected states and the degree of overlap across programs may vary from state to state. However, the scope of this report did not allow us to gather enough information to discuss the level of overlap or extent of administrative efficiencies among food assistance programs on a national level. Some programs provide comparable benefits to similar population and are managed separately--a potentially inefficient use of federal funds. While the programs in this study do not exactly duplicate each others' services, some provide comparable benefits to similar target populations--this may be in part because they were created separately to meet various needs. For example, six programs--the National School Lunch Program, the School Breakfast Program, the Fresh Fruit and Vegetable Program, the Summer Food Service Program, the Special Milk Program, and the Child and Adult Care Food Program--all provide food to eligible children in settings outside the home, such as at school, day care, or summer day camps. Also, the Commodity Supplemental Food Program provides food to the elderly and to women, infants, and children up to age six. These populations are targeted by other programs as well. The Elderly Nutrition Program primarily serves individuals 60 years and older and WIC serves pregnant and postpartum women and children up to age five. In addition, individuals eligible for groceries through the Commodity Supplemental Food Program are generally eligible for groceries through The Emergency Food Assistance Program and for SNAP.[Footnote 65] The Federal Emergency Management Agency's Emergency Food and Shelter National Board Program and USDA's Emergency Food Assistance Program both provide groceries and prepared meals to needy individuals through local government and nonprofit entities. As another example, the Summer Food Service Program has similarities to the Summer Seamless Option of the National School Lunch Program. However, the two programs have different reporting requirements and reimbursement rates and, as an official explained, this difference made his school choose between the Summer Food Service Program's higher reimbursement rate and the Seamless Summer Option's fewer reporting requirements. GAO has found that program overlap--having multiple programs provide comparable benefits to similar target populations--is an inefficient use of federal funds.[Footnote 66] Like other social service programs, most food assistance programs have specific and often complex administrative procedures that federal, state, and local organizations follow to help manage each program's resources and provide assistance. Government agencies and local organizations dedicate staff time and resources to separately manage the programs even when a number of the programs are providing comparable benefits to similar groups and could potentially be consolidated. Previous GAO work indicates that combining programs could reduce administrative expenses by eliminating duplicative efforts, such as eligibility determination and data reporting.[Footnote 67] However, some officials and providers express concern that such consolidation would make it more difficult to serve people in need and easier to reduce funds specifically dedicated to providing food assistance. Consolidating to improve program efficiency presents other tradeoffs as well. Most of the 18 programs, including the small programs, were designed to target assistance to specific populations or meet the specific needs of certain populations. Efforts to reduce overlap could detract from the goals of some of the programs. For example, programs focused on improving the nutritional status of participants may use a different approach than programs focused on reducing food insecurity even if both programs are available to the same or similar target groups, and efforts to reduce overlap could make it difficult to achieve both goals. Overlapping eligibility requirements create duplicative work for providers and applicants. According to previous GAO work and the officials we spoke with, overlapping program rules related to determining eligibility often require local providers to collect similar information--such as an applicant's income and household size-- multiple times because this information is difficult to share, partly due to concerns for safeguarding individuals' confidentiality but also due to incompatible data systems across programs. In addition, some of these rules often require applicants who seek assistance from multiple programs to submit separate applications for each program and provide similar information verifying, for example, household income. Some local providers and state officials told us families with the greatest needs often access multiple programs in an attempt to ensure they have enough food to eat. The application process is made even more challenging for families when the programs are physically housed in a wide range of government agencies or nonprofit organizations within the community. USDA has taken steps to address some of these inefficiencies. To align eligibility procedures and encourage participation, especially among its largest programs, USDA has policies in place that often make it simpler for recipients of one program to receive benefits in another. For example, evidence of SNAP participation is one way for a mother to show that her income is low enough to qualify for WIC. USDA also has instituted direct certification for its child nutrition programs, including the National School Lunch Program, the School Breakfast Program, and the Child and Adult Care Food Program. Direct certification allows state SNAP offices to share their local enrollment lists with school districts so that children in households receiving SNAP can automatically be determined eligible to receive free school meals without having to complete a separate application. Education officials we talked with who have established direct certification with SNAP believe that it reduces work for both the school districts and the families. However, the process to directly certify eligible school-aged children is not always effective. USDA has estimated that 10 million children were eligible for direct certification at the start of the 2008-2009 school year, but only 6.5 million were directly certified. Consequently, the families of approximately 2 million children completed and submitted two similar applications: one for SNAP and one for free or reduced-priced school meals. Further, as many as 1.5 million children may not be receiving free school meals because they were not automatically enrolled through direct certification and their parents or guardians did not apply. USDA has also taken steps to coordinate programs--including those related to nutrition education--within the Food and Nutrition Service as well as across state agencies and local providers. In 2003 USDA initiated State Nutrition Action Plans in part to advance cross- program integration among the nutrition education component of the federal food assistance programs at the state level. Through this process, state teams identify a common goal and formulate a plan for working together across programs to achieve that goal. In 2004, soon after USDA initiated efforts to integrate its nutrition education programs, GAO reviewed USDA's nutrition education programs[Footnote 68] and identified challenges related to program overlap.[Footnote 69] For example, GAO found that while nutrition educations programs share similar target populations and nutrition education goals, they lacked strong coordination, which can result in, among other things, inefficient use of resources. In addition, GAO found that the programs' different administrative structures hindered coordination among nutrition education efforts. In response to this 2004 report, USDA made a number of efforts to improve coordination among its nutrition education programs and strength linkages among them. For example, USDA established Nutrition.gov, a Web site which provides a variety of information on nutrition education and describes USDA's food assistance programs. USDA has also taken a number of steps to systematically collect reliable data and identify and disseminate lessons-learned for its nutrition education efforts.[Footnote 70] Another example of USDA's efforts to increase coordination across program services is by permitting their regional offices to retain a small percentage of WIC funds--also known as WIC operational adjustment funds--to support regional priorities including, for example, coordinating food assistance programs at the state and local levels. One such coordination effort at the local level made possible through WIC operational adjustment funds, was in Alameda County, California, where a group of local providers meets regularly to discuss ways to coordinate their food assistance programs. Among this group's accomplishments is a pamphlet that provides information in both English and Spanish on how to access services through the several federal food assistance programs in their community, such as SNAP benefits, WIC services, school meals for children, and emergency food services offered through the local food bank (see figure 9). This group is also actively pursuing funding for piloting a universal application so that individuals interested in applying for multiple food assistance programs can complete one application instead of several. During our visits to rural areas of California and Maryland, we learned that local coordination efforts were less structured and based more on personal connections among program officials and between service providers. Figure 9: Page Three of Alameda County Nutrition Action Partners' Free Food Programs Brochure: [Refer to PDF for image: brochure page] Alameda County Nutrition Food Assistance Programs: Need More Money for Groceries? You may be eligible for the Food Stamp Program! Food Stamps can help provide money for nutritious foods for your family. * A family can earn up to 130% of the Federal Poverty Income Guideline per month and qualify. For example, a family of three can have an income of up to $2,420 per month before taxes. * A family of three, for example, could receive up to $463 in food stamp benefits per month. To apply, you will need: ID, proof of income (check stubs, etc.), proof of assets (bank account, etc.), proof of expenses (rent, utility bills and medical bills). For more information or to find out where to apply, call 1-888-999- 4772 or visit the website at: www.alamedasocialservices.org. For help in filling out the application, call 1-800-870-3663. Have Children in School? They may be eligible for a free or reduced price breakfast and/or lunch. * If you or your children currently receive Food Stamps, CalWorks, KinGAP, FDPIR benefits, are foster children or placed in out of home care, they are eligible. * If your children are on WIC they may be eligible. Apply anytime during the school year. Applications are available at your school. Call your child's school for more information. Raising Babies or Children Under Five? You may be eligible for the Women, Infants, and Children (WIC) program. WIC offers nutrition advice, help with breastfeeding, and healthy food. WIC serves pregnant and breastfeeding women, infants and children under the age of 5. * A family can earn up to 185% of the Federal Poverty Income Guideline per month and qualify. For example, a family of three can have an income of up to $2,714 per month before taxes. * A family of three, for example, could receive about $150 of nutritious foods every month. To apply you will need ID, proof of income and also proof of address. Call (510) 595-6400 for more information, and to see if you're eligible. Need Food Immediately? Call the Food Helpline at: 1-800-870-FOOD (3663). The Alameda County Community Food Bank will refer you to a location in your neighborhood where you can get a bag of groceries or a hot meal today. Source: Alameda County Nutrition Action Partners. [End of figure] Throughout our site visits, some state officials and local providers told us they would like to see the federal government do more to coordinate its food and nutrition assistance programs. For example, a director of a nongovernmental organization (NGO) that provides food assistance through the Elderly Nutrition Program and the Emergency Food and Shelter National Board Program explained that he is not always clear about what federal food assistance programs are available to NGOs or which ones are best suited for his organization's mission and resources. The NGO director suggested that federal agencies work together to build a Web site that identifies the various food assistance programs and provides information--such as programs' eligibility, administrative, and funding requirements--to help local providers determine if their NGOs have the right type of mission and sufficient personnel and funding to provide assistance funded by certain federal programs. According to this local provider, having consolidated information on all the food assistance programs would help organizations determine what federal food assistance program best matches their mission and resource capacity. Conclusion: The federal government spends billions of dollars every year to support a food assistance structure that, while critical to addressing some of the most basic needs facing the nation's most vulnerable individuals, shows signs of potential overlap and inefficiency among its programs. With the growing rate of food insecurity among U.S. households and significant pressures on the federal budget, it is important to understand not only the extent to which food assistance programs complement one another to better meet program goals but also the extent to which program services and administrative requirements may overlap and create duplication that adversely impacts program effectiveness and efficiency. While research indicates that the largest programs have positive outcomes consistent with their program goals, limited research on most of the smaller programs makes it difficult to determine whether these are filling an important gap or whether they are unnecessarily duplicating functions and services of other programs. It is only by looking more closely at the goals, benefits, and target populations of the many smaller programs that the federal government can begin to develop methods to help reduce inefficiencies and save administrative resources while at the same time ensuring that those who are eligible receive the assistance they need. Furthermore, for the programs that have complementary goals, functions, and services, there may be ways to more efficiently fulfill administrative requirements and processes. Small changes to increase administrative efficiencies, such as additional efforts to align application procedures, could be made in the near-term; however, larger changes involving program duplication will require careful attention to the potential effects on those currently receiving assistance. Without such efforts, resources may be wasted or those in need may not be able to access enough food for a healthy, productive life. Recommendation for Executive Action: We recommend that the Secretary of Agriculture, as the principal administrator of the federal government's food assistance programs, identify and develop methods for addressing potential inefficiencies among food assistance programs and reducing unnecessary overlap among the smaller programs while ensuring that those who are eligible receive the assistance they need. Approaches may include conducting a study; convening a group of experts (consistent with the Federal Advisory Committee Act), including, for example, representatives of the 18 food assistance programs, state representatives, and local providers; considering which of the lesser-studied programs need further research; or piloting proposed changes. Recommendations from further study could be used by administering agencies or, if appropriate, by Congress to improve the federal government's food assistance system. Agency Comments and Our Evaluation: We shared a draft of this report with USDA, HHS, and DHS for review and comment. The following summarizes the response from each agency. On March 10, 2010, USDA provided informal comments via e-mail. USDA stated that our analysis was thoughtful and objective. However, the agency expressed concern that our discussion of the overlap and duplication of nutrition assistance programs in the body of the report may be overlooked by readers who focus on the summary and conclusion. USDA emphasized that no single nutrition assistance program is designed to meet all of a family's nutrition needs, and that participation in one or more of the largest nutrition assistance programs does not guarantee food security. Additionally, while they may appear similar in terms of the general demographic characteristics of their target populations, USDA noted that programs vary with respect to how well they fit the needs of different subgroups and no single program attracts or serves everyone in its respective target audience. For example, some individuals--like the homeless or elderly-- may find it difficult to prepare their own meals and instead need already prepared meals, such as those provided by The Emergency Food Assistance Program and the Child and Adult Care Food Program. The agency also emphasized that fundamental change to improve program efficiency requires legislation that facilitates program integration. USDA concluded by stating that it will consider the value of a study to examine potential inefficiencies and overlap among smaller programs. However, the agency explained that it has generally focused research efforts on large programs as the most cost-effective use of the limited dollars available. We should note that our recommendation includes the need to address unnecessary overlap and duplication among smaller programs but also refers to the need to identify and develop methods for addressing potential inefficiencies among food assistance programs overall, which would include the larger programs that have complementary goals but often have separate administrative systems and eligibility requirements. USDA also expressed concern that in the absence of a specific appropriation for such a study, any allocation of resources to this effort would shift resources away from other projects and priorities. We believe that conducting study is one possible method for addressing potential inefficiencies and reducing overlap among smaller programs. Other approaches--such as convening a group of experts--may be as effective and require fewer resources. HHS agreed with the report's finding that the Elderly Nutrition programs directly address program goals. In addition, HHS agreed that federal programs should aim to achieve the greatest efficiency, effectiveness, and reduction of duplication and overlap. The agency stated its view that the Older Americans Act Nutrition Services programs complement, not duplicate, USDA's food and nutrition assistance programs. HHS's written comments appear in appendix IV. DHS Federal Emergency Management Agency provided technical comments, most of which provided clarification and were incorporated in the report where appropriate. We are sending copies of this report to relevant congressional committees; the Secretaries of Agriculture, Health and Human Services, and Homeland Security; and other interested parties. The report also will be available at no charge on the GAO Web site at [hyperlink, http://www.gao.gov]. If you or your staff have any questions about this report, please contact me at (202) 512-7215 or brownke@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Key contributors to this report are listed in appendix V. Sincerely Yours, Signed by: Kay E. Brown: Director, Education, Workforce, and Income Security Issues: [End of section] Appendix I: Objectives, Scope, and Methodology: Program Selection: In selecting programs for this review, we defined the scope to include only federal programs that focus primarily on providing or supporting food and nutrition assistance in the United States. We identified these programs by reviewing the Catalog of Federal Domestic Assistance (CFDA), [Footnote 71] relevant federal laws and regulations, and relevant documents. We also met with federal officials and relevant experts. Using key words related to food and nutrition assistance and other social services, we conducted a systematic search in the CFDA to identify programs that have some role in providing food and nutrition assistance and the respective agencies responsible for administering each of these programs.[Footnote 72] We also interviewed federal officials and reviewed agencies' Web sites. In addition, we reviewed related federal legislation--such as the Food, Conservation, and Energy Act of 2008 (2008 Farm Bill) and Child Nutrition and WIC Reauthorization Act of 2004--to search for new grant programs or pilot projects that provide or support food and nutrition assistance. From this search, we identified 70 potential food and nutrition-related programs. Using our initial collection of 70 programs, we limited the list to programs that (1) mentioned food or nutrition assistance in their CFDA profile or on the agency's Web site or (2) allowed funds to be used to build the infrastructure within or the coordination across food and nutrition assistance programs. We then excluded any programs that met one or more of the following: * Food and nutrition assistance is not the primary objective of the program, but is one of multiple social support services. * Program did not exist or was not funded in fiscal year 2008. * Programs provide fungible funds to states or individuals that may be used for, but are not required to be spent on, the purchase of food. * Program supports infrastructure costs that support a range of programs or a facility, which can include, but are not limited to, food and nutrition assistance-related functions. * Dedicated funding stream that supports a program or a component of a food assistance program already included in our review. For example, the Nutrition Services Incentive Program (NSIP) provides funds and commodities to support two Department of Health and Human Services (HHS) programs: the Elderly Nutrition Program: Home-Delivered and Congregate Nutrition Services, and Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services; therefore, we did not consider NSIP as a separate program in this review). * Federal efforts that process or deliver food to organizations that administer food and nutrition assistance programs, such as the food distribution and price support functions of the U.S. Department of Agriculture's (USDA) Farm Service Agency. * Program funds that are directed toward research or nutritional education or outreach only. We excluded programs that focus solely on nutrition education because of previous GAO work in this area.[Footnote 73] Examples of nutrition education programs include Team Nutrition Initiative and Expanded Food and Nutrition Education Program. Other programs that have nutrition education components but primarily provide food assistance--such as the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the National School Lunch Program, and the Child and Adult Care Food Program--are included in this review. Once initial program determinations were made, we sent e-mails to the agencies that had only programs excluded from our program list. These agencies included the Corporation for National and Community Service (CNCS), Department of Defense (DOD), Department of Housing and Urban Development (HUD), Department of Veterans Affairs (VA), and the following offices within HHS: Administration for Children and Families; Health, Resources, and Services Administration; Indian Health Services; Centers for Medicare and Medicaid Services (CMS); and Centers for Disease Control and Prevention (CDC). All liaisons confirmed our exclusion decisions, with the exception of officials from CMS.[Footnote 74] For the agencies with programs that met our inclusion criteria, we held follow-up meetings or corresponded with agency liaisons from three agencies--USDA, HHS, and the Department of Homeland Security (DHS)--to confirm or offer feedback on our decisions. This process resulted in the 18 programs included in our engagement. See table 6 for a full list of included and excluded programs. Figure 10: Programs Included and Excluded from Our Review: [Refer to PDF for image: table] Program: Child and Adult Care Food Program; Agency/office: USDA-Food and Nutrition Service (FNS); Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Commodity Supplemental Food Program (CSFP): Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Community Food Projects Competitive Grants Program (CFP); Agency/office: USDA-National Institute of Food and Agriculture (NIFA); Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Food Distribution Program on Indian Reservations (FDPIR); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Fresh Fruit and Vegetable Program (FFVP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: National School Lunch Program (NSLP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Nutrition Assistance for Puerto Rico (NAP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: School Breakfast Program (SBP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Senior Farmers' Market Nutrition Program (SFMNP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Special Milk Program (SMP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Summer Food Service Program (SFSP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: SNAP; Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: The Emergency Food Assistance Program (TEFAP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: WIC (Special Supplemental Nutrition Program for Women, Infants, and Children); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: WIC Farmers' Market Nutrition Program (FNMP); Agency/office: USDA-FNS; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Emergency Food and Shelter National Board Program (EFS); Agency/office: DHS-Federal Emergency Management Agency (FEMA); Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Elderly Nutrition Program: Home-Delivered and Congregate Nutrition Services; Agency/office: HHS-Administration on Aging (AOA); Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services; Agency/office: HHS-AOA; Included: Yes; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Programs excluded from the review: Program: Foster Grandparent Program (FGP); Agency/office: CNCS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Retired and Senior Volunteer Program (RSVP); Agency/office: CNCS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: Exclusion criteria: Was not funded or did not exist in fiscal year 2008: Exclusion criteria: Is a funding stream or component of another program: Program: Senior Companion Program (SCP); Agency/office: CNCS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: Exclusion criteria: Funding is for research, education, or counseling only: Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Volunteers in Service to America (VISTA); Agency/office: CNCS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Family Subsistence Supplemental Allowance (FSSA); Agency/office: DOD; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Basic Center Grant; Agency/office: HHS-Administration for Children and Families (ACF); Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Empty]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Community Services Block Grant; Agency/office: HHS-ACF; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Head Start; Agency/office: HHS-ACF; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Social Services Block Grant; Agency/office: HHS-ACF; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Empty]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: NSIP; Agency/office: HHS-AOA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: Special Programs for the Aging - Title III.B Supportive Services and Senior Centers Program; Agency/office: HHS-AOA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Empty]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Healthy Communities Program; Agency/office: HHS-CDC; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Check]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Medical Nutrition Therapy; Agency/office: HHS-CMS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Check]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Emergency Shelter Grants Program (ESG); Agency/office: HUD-Office of Community and Planning Development (OCPD); Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Empty]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Check]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Housing Opportunities for Persons with AIDS (HOPWA); Agency/office: HUD-OCPD; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Check]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Assisted Living Conversion for Eligible Multifamily Housing Projects; Agency/office: HUD-Office of the Federal Housing Commissioner; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Empty]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Check]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Cooperative Extension Service; Agency/office: USDA-NIFA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Check]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Expanded Food and Nutrition Education Program (EFNEP); Agency/office: USDA-NIFA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Check]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: SNAP Outreach/Participation Program; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: WIC Grants to States; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: Child Nutrition Discretionary Grants Limited Availability; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: DOD Fresh Fruit and Vegetable Program (DOD-Fresh); Agency/office: DOD-DSCP; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Check]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Food Assistance and Nutrition Research Programs (FANRP); Agency/office: USDA-Economic Research Service (ERS); Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Check]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: FNS Disaster Assistance; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: National Nonprofit Humanitarian Initiative; Agency/office: USDA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Nutrition Assistance Program: American Samoa; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: Nutrition Assistance Program: Northern Marianas Islands; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: Nutrition Education and Training; Agency/office: USDA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Check]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: State Administrative Expenses for Child Nutrition; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: State Administrative Matching Grants for SNAP; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: Team Nutrition Initiative Grants; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Check]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: TEFAP Administrative Costs; Agency/office: USDA-FNS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: Dairy Product Price Support Program; Agency/office: USDA-Farm Service Agency (FSA); Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Check]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Community Facilities Loans and Grants; Agency/office: USDA-Rural Development (RD); Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Empty]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Check]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Veterans State Adult Day Health Care; Agency/office: VA-NCS; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Check]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Empty]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. 2008 Farm Bill programs excluded from the review: Program: Healthy Incentives Pilot (HIP); Agency/office: USDA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Check]. Program: Emergency Food Program Infrastructure Grants; Agency/office: USDA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Hunger Free Communities Grants; Agency/office: USDA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. American Recovery and Reinvestment Act of 2009 funding streams excluded from the review: Program: Home-Delivered Nutrition Services; Agency/office: HHS-AOA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Nutrition Services for Native Americans; Agency/office: HHS-AOA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Congregate Nutrition Services; Agency/office: HHS-AOA Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: The Emergency Food and Shelter National Board Program; Agency/office: DHS-FEMA; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Empty]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Empty]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Program: Community Services Block Grant; Agency/office: HHS-ACF; Included: No; Inclusion criteria: Mentions food assistance or nutrition in program description: [Check]; Inclusion criteria: Money for infrastructure or coordination of food and nutrition assistance: [Check]; Exclusion criteria: Funding is for research, education, or counseling only: [Empty]; Exclusion criteria: Funding is fungible, without required food spending: [Check]; Exclusion criteria: USDA commodity processing and distribution: [Empty]; Exclusion criteria: Food and nutrition assistance is not the primary objective: [Empty]; Exclusion criteria: Infrastructure spending is for multiple types of facilities, or multipurpose facilities, that may include food and nutrition: [Empty]; Exclusion criteria: Was not funded or did not exist in fiscal year 2008: [Check]; Exclusion criteria: Is a funding stream or component of another program: [Empty]. Source: GAO. Note: Nine additional programs were initially reviewed after being included in keyword searches of the CFDA or being recommended by federal experts; however, these programs did not meet either of the two inclusion criteria. As a result they were eliminated from consideration before comparing against exclusion criteria. These included six programs in HHS: Temporary Assistance for Needy Families and Family Violence Prevention and Services: Grants for Battered Women's Shelters; Grants to States and Indian Tribes, both in the Administration for Children and Families; the Ryan White HIV/AIDS Program, in the Health Resources and Services Administration; Indian Health Services; the Medicaid Home and Community-Based Services Waiver in the Centers for Medicare and Medicaid Services; and Special Programs for the Aging Title III. Part D Disease Prevention and Health Promotion Services, in the AOA. Two of the programs were in HUD: Demolition and Revitalization of Severely Distressed Public Housing and the Supportive Housing Program. The final program was in the VA: the VA Homeless Providers Grants and Per Diem Program. [End of figure] Food Security Data: To show the prevalence of food insecurity among U.S. households from 1995 to 2008, we presented data from the Current Population Survey (CPS), a nationally representative survey with comparable measures across years. Food insecurity is measured each year by the USDA Economic Research Service using the Food Security Supplement of the CPS. The survey asks individuals 10 questions (18 questions are asked if the household contains children 18 years of age or younger) about behaviors or conditions known to characterize households having difficulty meeting basic food needs. The answers to the survey questions determine the food security status of each household and, collectively, allow USDA to monitor and track changes in food insecurity among U.S. households. The food insecurity prevalence rates are sample-based estimates. All food security rates presented in this report are statistically significant (different than zero) at the 90 percent confidence level, and rates for different subpopulations are presented only where there are statistically significant differences between these populations. More information on the confidence intervals around the food insecurity estimates is presented in appendix II. While the food security data have some limitations, we consider these data reliable and appropriate for this engagement. See appendix II for more information on the food security data. Program Spending: To determine how much money federal agencies spent on food and nutrition programs, we analyzed data from the Consolidated Federal Funds Report (CFFR)--a database that compiles expenditures or obligations from federal agencies.[Footnote 75] These data are not entirely consistent across programs. For example, USDA agency officials reported obligations, while the Administration on Aging reported the amounts in the CFFR are comparable to the amount of federal funds that states and tribes spent in fiscal year 2008 to support the agency's nutrition assistance programs. Programs also differ in whether and how they report funds dedicated to administrative efforts to the CFFR. In addition, agency officials told us that some spending amounts were not included in the CFFR, and for those programs, we contacted agencies directly to obtain spending amounts. Once we compiled the spending amounts for each program, we contacted budget officials at each agency to confirm the amounts. In several cases, we combined the CFFR totals with additional spending information provided by agency officials, to ensure an accurate reporting of spending (see notes in table 2). After speaking with agency officials and interviewing a federal Census Bureau official with detailed knowledge of the CFFR database, we determined the data are reliable and appropriate for our engagement. Program Participation: In order to determine the number of individuals and households participating in USDA, HHS, and DHS food and nutrition assistance programs and the quantity of benefits distributed, the team relied on publicly available data from these agencies. Because these data are being used for background purposes only, we did not conduct a reliability assessment of these data. Program Effectiveness: To determine what is known about the effects food and nutrition assistance programs have on outcomes related to their program goals, we began by compiling a list of program goals based on our review of federal statutes, regulations, or discussions with agency officials. Footnote 76] We then used a large scale literature review conducted by the Economic Research Service of USDA and conducted our own, smaller- scale literature review of studies that addressed the impacts of food and nutrition assistance programs. The Economic Research Service literature review--Effects of Food Assistance and Nutrition Programs on Nutrition and Health--evaluated available research on the effectiveness of USDA food and nutrition assistance programs produced or published between 1973 and 2002. Our literature review was designed to capture research on USDA programs published between January 2002 and March 2009, as well as programs administered by HHS and DHS between January 1995 and March 2009. Our initial literature searches returned hundreds of studies. We then narrowed the results using criteria that included research that examined (1) program participation effects on nutrition or health related outcomes and (2) the effects of the programs on the agricultural economy, which contained a comparison between a participant and nonparticipant group or was longitudinal in nature.[Footnote 77] These criteria allowed us to reduce the number of potential studies to fewer than 125. From this list we selected a sample of 35 studies to review. To ensure our sample did not inadvertently omit any seminal research we consulted experts at USDA and HHS. Due to the limited available research on smaller programs, identified studies of these programs were automatically included. Each of the 35 studies chosen was systematically reviewed and information on the study's design, methodology, limitations, and findings was compiled and analyzed. Of the 35 studies, we deemed five to be too methodologically flawed or limited for our purposes. Although the Economic Research Service literature review and the research selected for our literature review were considered to be methodologically sound, it is important to understand that certain limitations may prevent firm conclusions regarding the effects of the programs. For example, the data used in some of the studies is dated and programs may have changed substantially since the data was collected or the research was completed. In addition, some of the research examined pilot or demonstration projects and thus only provide suggestive evidence for actual program impacts. The samples used in some studies may prevent generalizing their findings to wider populations. Furthermore, selection bias is a concern in much of the literature as few randomized controlled experiments exist. Selection bias can occur for many reasons--for example, in voluntary programs, those who chose to participate (or stop participating) may be systematically different from those who chose not to participate and its consequence can be to make a program appear more (or less) effective than it actually is. With few exceptions, the academic literature related to programs' effectiveness did not directly examine whether programs were meeting their legislative and program goals. Therefore, we were required to assess which program outcomes addressed in the literature were related to these goals. To do this, we first identified the goals of each program by reviewing relevant federal statues and regulations, as well as consulting agency officials. Second we reviewed the impacts addressed in the literature reviewed and assessed which program goals, if any, they were related to. We then assessed the relevance of each impact to each program goal. A GAO economist independently performed a similar assessment. Last the assessments were reconciled with the help of the methodologist assisting on the engagement. The methodology for our determinations regarding which program outcomes were related to which program goals was shared with agency officials who expressed no concerns about its validity. Site Visits: We visited California, Illinois, and Maryland. We also conducted phone interviews with officials and providers in Oregon and Texas. The states that we selected represent a combination of urban and rural demographics and geographic distribution. We also selected states and local areas based on recommendations from federal and state officials and relevant experts. The information we collected from our site visits helped inform our understanding of the complex issues related to food assistance. These site visits also helped us better understand the implications of providing food assistance through multiple programs and agencies. We conducted this performance audit from February 2009 to March 2010 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence we obtained provides a reasonable basis for our findings and conclusions. [End of section] Appendix II: The Prevalence of Food Insecurity among U.S. Households from 1995 to 2008 and the Issues Affecting Food Insecurity Data: Figure 11: Prevalence of Food Insecurity in U.S. Households from 1995 to 2008: [Refer to PDF for image: multiple line graph] Percentage of households: Year: 1995; Very low food security, adjusted for comparability in all years[A]: 3.9%; Low and very low food security, adjusted for comparability in all years[A]: 10.3%. Year: 1996; Very low food security, adjusted for comparability in all years[A]: 4.1%; Low and very low food security, adjusted for comparability in all years[A]: 10.4%. Year: 1997; Very low food security, adjusted for comparability in all years[A]: 3.1%; Low and very low food security, adjusted for comparability in all years[A]: 8.7%. Year: 1998; Very low food security, adjusted for comparability in all years[A]: 3.51%; Very low food security, data as collected (unadjusted): 3.71%; Low and very low food security, adjusted for comparability in all years[A]: 10.1%; Low and very low food security, data as collected (unadjusted): 11.79%. Year: 1999; Very low food security, adjusted for comparability in all years[A]: 2.85%; Very low food security, data as collected (unadjusted): 2.97%; Low and very low food security, adjusted for comparability in all years[A]: 8.73%; Low and very low food security, data as collected (unadjusted): 10.06%. Year: 2000; Very low food security, adjusted for comparability in all years[A]: 2.95%; Very low food security, data as collected (unadjusted): 3.13%; Low and very low food security, adjusted for comparability in all years[A]: 9.09%; Low and very low food security, data as collected (unadjusted): 10.47%. Year: 2001; Very low food security, adjusted for comparability in all years[A]: 3.05%; Very low food security, data as collected (unadjusted): 3.26%; Low and very low food security, adjusted for comparability in all years[A]: 9.18%; Low and very low food security, data as collected (unadjusted): 10.69%. Year: 2002; Very low food security, adjusted for comparability in all years[A]: 3.36%; Very low food security, data as collected (unadjusted): 3.5%; Low and very low food security, adjusted for comparability in all years[A]: 9.67%; Low and very low food security, data as collected (unadjusted): 11.1%. Year: 2003; Very low food security, adjusted for comparability in all years[A]: 3.32%; Very low food security, data as collected (unadjusted): 3.49%; Low and very low food security, adjusted for comparability in all years[A]: 9.76%; Low and very low food security, data as collected (unadjusted): 11.21%. Year: 2004; Very low food security, adjusted for comparability in all years[A]: 3.77%; Very low food security, data as collected (unadjusted): 3.94%; Low and very low food security, adjusted for comparability in all years[A]: 10.41%; Low and very low food security, data as collected (unadjusted): 11.95%. Year: 2005; Very low food security, adjusted for comparability in all years[A]: 3.67%; Very low food security, data as collected (unadjusted): 3.87%; Low and very low food security, adjusted for comparability in all years[A]: 9.58%; Low and very low food security, data as collected (unadjusted): 11%. Year: 2006; Very low food security, adjusted for comparability in all years[A]: 3.77%; Very low food security, data as collected (unadjusted): 3.99%; Low and very low food security, adjusted for comparability in all years[A]: 9.6%; Low and very low food security, data as collected (unadjusted): 10.94%. Year: 2007; Very low food security, adjusted for comparability in all years[A]: 3.9%; Very low food security, data as collected (unadjusted): 4.06%; Low and very low food security, adjusted for comparability in all years[A]: 9.84%; Low and very low food security, data as collected (unadjusted): 11.11%. Year: 2008; Very low food security, adjusted for comparability in all years[A]: 5.53%; Very low food security, data as collected (unadjusted): 5.7%; Low and very low food security, adjusted for comparability in all years[A]: 13.06%; Low and very low food security, data as collected (unadjusted): 14.6%. Note: Food insecurity prevalence rates are sample-based estimates. The calculation of confidence intervals around the food insecurity rates is discussed in this appendix. [A] Due to changes in screening procedures, food security statistics from 1995 to 1997 are not directly comparable with those from 1998 to 2008. The dotted lines represent data that have been adjusted for comparability across all years. [End of figure] Food insecurity data collected between 1995 and 2000 are affected by (1) a change in screening procedures and (2) a change in the months during which food security data were collected. Screening procedures. Because of changes in screening procedures used to reduce respondent burden, food security statistics from 1995 to 1997 are not directly comparable with those from 1998 to 2008. The dotted lines in figure 10 represent statistics as collected for the years 1995 to 1997, and the dotted lines that continue after 1997 show data that have been adjusted to be comparable across all years. The solid lines show data as collected for the years 1998 to 2008. Data collection. The CPS food security surveys between 1995 and 2000 alternated between April in odd-numbered years and August or September in even-numbered years. The measured prevalence of food insecurity was higher in the August/September collections, suggesting a seasonal response effect. Since 2001 the survey has been conducted in early December, which avoids further problems of seasonality effects in interpreting annual changes. Food insecurity prevalence rates are sample-based estimates that have associated confidence intervals. Standard errors are based on a design factor of 1.6 due to the complex sampling design of the CPS; that is, the standard error of an estimated proportion is calculated as [P X (1- P) X 1.6]/N, where P is the estimated proportion and N is the unweighted number of households in the denominator. (Standard errors for state-level estimates, which are not presented in this report, are calculated differently.) The estimated 90 percent confidence intervals around the food insecurity prevalence rates for 1998 to 2008 are presented in table 6.[Footnote 78] Table 1: Estimates and 90 Percent Confidence Intervals for Food Security, Low Food Security, and Very Low Food Security, 1998 to 2008: Year: 2008; Estimated proportion of households that are food secure: Lower bound: 82.6; Estimated proportion of households that are food secure: Estimate: 85.4; Estimated proportion of households that are food secure: Upper bound: 88.2; Estimated proportion of households that are food insecure: Lower bound: 11.8; Estimated proportion of households that are food insecure: Estimate: 14.6; Estimated proportion of households that are food insecure: Upper bound: 17.4; Estimated proportion of households with low food security: Lower bound: 7.1; Estimated proportion of households with low food security: Estimate: 8.9; Estimated proportion of households with low food security: Upper bound: 10.7; Estimated proportion of households with very low food security: Lower bound: 4.5; Estimated proportion of households with very low food security: Estimate: 5.7; Estimated proportion of households with very low food security: Upper bound: 6.9. Year: 2007; Estimated proportion of households that are food secure: Lower bound: 86.7; Estimated proportion of households that are food secure: Estimate: 88.9; Estimated proportion of households that are food secure: Upper bound: 91.1; Estimated proportion of households that are food insecure: Lower bound: 8.9; Estimated proportion of households that are food insecure: Estimate: 11.1; Estimated proportion of households that are food insecure: Upper bound: 13.3; Estimated proportion of households with low food security: Lower bound: 5.5; Estimated proportion of households with low food security: Estimate: 7; Estimated proportion of households with low food security: Upper bound: 8.5; Estimated proportion of households with very low food security: Lower bound: 3.2; Estimated proportion of households with very low food security: Estimate: 4.1; Estimated proportion of households with very low food security: Upper bound: 5. Year: 2006; Estimated proportion of households that are food secure: Lower bound: 86.9; Estimated proportion of households that are food secure: Estimate: 89.1; Estimated proportion of households that are food secure: Upper bound: 91.3; Estimated proportion of households that are food insecure: Lower bound: 8.7; Estimated proportion of households that are food insecure: Estimate: 10.9; Estimated proportion of households that are food insecure: Upper bound: 13.1; Estimated proportion of households with low food security: Lower bound: 5.4; Estimated proportion of households with low food security: Estimate: 6.9; Estimated proportion of households with low food security: Upper bound: 8.4; Estimated proportion of households with very low food security: Lower bound: 3.1; Estimated proportion of households with very low food security: Estimate: 4; Estimated proportion of households with very low food security: Upper bound: 4.9. Year: 2005; Estimated proportion of households that are food secure: Lower bound: 86.7; Estimated proportion of households that are food secure: Estimate: 89; Estimated proportion of households that are food secure: Upper bound: 91.3; Estimated proportion of households that are food insecure: Lower bound: 8.7; Estimated proportion of households that are food insecure: Estimate: 11; Estimated proportion of households that are food insecure: Upper bound: 13.3; Estimated proportion of households with low food security: Lower bound: 5.6; Estimated proportion of households with low food security: Estimate: 7.1; Estimated proportion of households with low food security: Upper bound: 8.6; Estimated proportion of households with very low food security: Lower bound: 3; Estimated proportion of households with very low food security: Estimate: 3.9; Estimated proportion of households with very low food security: Upper bound: 4.8. Year: 2004; Estimated proportion of households that are food secure: Lower bound: 85.6; Estimated proportion of households that are food secure: Estimate: 88.1; Estimated proportion of households that are food secure: Upper bound: 90.6; Estimated proportion of households that are food insecure: Lower bound: 9.4; Estimated proportion of households that are food insecure: Estimate: 11.9; Estimated proportion of households that are food insecure: Upper bound: 14.4; Estimated proportion of households with low food security: Lower bound: 6.3; Estimated proportion of households with low food security: Estimate: 8; Estimated proportion of households with low food security: Upper bound: 9.7; Estimated proportion of households with very low food security: Lower bound: 3; Estimated proportion of households with very low food security: Estimate: 3.9; Estimated proportion of households with very low food security: Upper bound: 4.8. Year: 2003; Estimated proportion of households that are food secure: Lower bound: 86.5; Estimated proportion of households that are food secure: Estimate: 88.8; Estimated proportion of households that are food secure: Upper bound: 91.1; Estimated proportion of households that are food insecure: Lower bound: 8.9; Estimated proportion of households that are food insecure: Estimate: 11.2; Estimated proportion of households that are food insecure: Upper bound: 13.5; Estimated proportion of households with low food security: Lower bound: 6; Estimated proportion of households with low food security: Estimate: 7.7; Estimated proportion of households with low food security: Upper bound: 9.4; Estimated proportion of households with very low food security: Lower bound: 2.7; Estimated proportion of households with very low food security: Estimate: 3.5; Estimated proportion of households with very low food security: Upper bound: 4.3. Year: 2002; Estimated proportion of households that are food secure: Lower bound: 86.5; Estimated proportion of households that are food secure: Estimate: 88.9; Estimated proportion of households that are food secure: Upper bound: 91.3; Estimated proportion of households that are food insecure: Lower bound: 8.7; Estimated proportion of households that are food insecure: Estimate: 11.1; Estimated proportion of households that are food insecure: Upper bound: 13.5; Estimated proportion of households with low food security: Lower bound: 5.9; Estimated proportion of households with low food security: Estimate: 7.6; Estimated proportion of households with low food security: Upper bound: 9.3; Estimated proportion of households with very low food security: Lower bound: 2.7; Estimated proportion of households with very low food security: Estimate: 3.5; Estimated proportion of households with very low food security: Upper bound: 4.3. Year: 2001; Estimated proportion of households that are food secure: Lower bound: 87; Estimated proportion of households that are food secure: Estimate: 89.3; Estimated proportion of households that are food secure: Upper bound: 91.6; Estimated proportion of households that are food insecure: Lower bound: 8.4; Estimated proportion of households that are food insecure: Estimate: 10.7; Estimated proportion of households that are food insecure: Upper bound: 13; Estimated proportion of households with low food security: Lower bound: 5.7; Estimated proportion of households with low food security: Estimate: 7.4; Estimated proportion of households with low food security: Upper bound: 9.1; Estimated proportion of households with very low food security: Lower bound: 2.5; Estimated proportion of households with very low food security: Estimate: 3.3; Estimated proportion of households with very low food security: Upper bound: 4.1. Year: 2000; Estimated proportion of households that are food secure: Lower bound: 87.2; Estimated proportion of households that are food secure: Estimate: 89.5; Estimated proportion of households that are food secure: Upper bound: 91.8; Estimated proportion of households that are food insecure: Lower bound: 8.2; Estimated proportion of households that are food insecure: Estimate: 10.5; Estimated proportion of households that are food insecure: Upper bound: 12.8; Estimated proportion of households with low food security: Lower bound: 5.6; Estimated proportion of households with low food security: Estimate: 7.3; Estimated proportion of households with low food security: Upper bound: 9; Estimated proportion of households with very low food security: Lower bound: 2.4; Estimated proportion of households with very low food security: Estimate: 3.1; Estimated proportion of households with very low food security: Upper bound: 3.8. Year: 1999; Estimated proportion of households that are food secure: Lower bound: 87.6; Estimated proportion of households that are food secure: Estimate: 89.9; Estimated proportion of households that are food secure: Upper bound: 92.2; Estimated proportion of households that are food insecure: Lower bound: 7.8; Estimated proportion of households that are food insecure: Estimate: 10.1; Estimated proportion of households that are food insecure: Upper bound: 12.4; Estimated proportion of households with low food security: Lower bound: 5.4; Estimated proportion of households with low food security: Estimate: 7.1; Estimated proportion of households with low food security: Upper bound: 8.8; Estimated proportion of households with very low food security: Lower bound: 2.3; Estimated proportion of households with very low food security: Estimate: 3; Estimated proportion of households with very low food security: Upper bound: 3.7. Year: 1998; Estimated proportion of households that are food secure: Lower bound: 85.5; Estimated proportion of households that are food secure: Estimate: 88.2; Estimated proportion of households that are food secure: Upper bound: 90.9; Estimated proportion of households that are food insecure: Lower bound: 9.1; Estimated proportion of households that are food insecure: Estimate: 11.8; Estimated proportion of households that are food insecure: Upper bound: 14.5; Estimated proportion of households with low food security: Lower bound: 6.2; Estimated proportion of households with low food security: Estimate: 8.1; Estimated proportion of households with low food security: Upper bound: 10; Estimated proportion of households with very low food security: Lower bound: 2.8; Estimated proportion of households with very low food security: Estimate: 3.7; Estimated proportion of households with very low food security: Upper bound: 4.6. Source: GAO calculations based on USDA data. [End of table] [End of section] Appendix III: Selected Program Goals: Table 7: Summary of Selected Food and Nutrition Assistance Program Goals: Program: Child and Adult Care Food Program; Summary of selected program goals[A]: * Assist states to initiate, maintain, and expand nonprofit food service programs for children or adults in nonresidential institutions which provide care; * Enable nonresidential institutions to provide nutritious food service to participants; * Improve the quality of meals or level of services provided or increase participation in the program at adult day care centers. Program: Commodity Supplemental Food Program; Summary of selected program goals[A]: * Provide food to help meet the nutritional needs of the target population. Program: Community Food Projects Competitive Grant Program; Summary of selected program goals[A]: * Meet the food needs of low-income individuals; * Increase the self-reliance of communities in providing for the food needs of the communities; * Promote comprehensive responses to local food, farm, and nutrition issues; * Meet specific state, local, or neighborhood food and agricultural needs, including needs relating to infrastructure improvement and development, planning for long-term solutions, or the creation of innovative marketing activities that mutually benefit agricultural producers and low-income consumers. Program: Elderly Nutrition Program: Home Delivered and Congregate Nutrition Services; Summary of selected program goals[A]: * Reduce hunger and food insecurity; * Promote socialization of older individuals; * Promote the health and well-being of older individuals by assisting such individuals to gain access to nutrition and other disease prevention and health promotion services to delay the onset of adverse health conditions resulting from poor nutritional health or sedentary behavior. Program: Emergency Food and Shelter National Board Program; Summary of selected program goals[A]: * Provide shelter, food, and supportive services to homeless individuals and to help them access other services; * Provide funding to help create more effective and innovative local programs; * Do minor rehabilitation to mass shelter and mass feeding facilities to make them safe, sanitary, and to bring them into compliance with local building codes; * Provide emergency food and shelter to needy individuals through private organizations and local governments. Program: Food Distribution Program on Indian Reservations; Summary of selected program goals[A]: * Raise the level of nutrition among low-income households; * Alleviate hunger and malnutrition in low-income households; * Increase food purchasing power for eligible households; * Strengthen the U.S. agricultural sector; * More orderly marketing and distribution of food; * Permit low-income households to obtain a more nutritious diet through normal channels of trade. Program: Fresh Fruit and Vegetable Program; Summary of selected program goals[A]: * Make fresh fruits and vegetables available in elementary schools. Program: Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services; Summary of selected program goals[A]: * Promote the delivery of supportive services, including nutrition services to American Indians, Alaskan Natives, and Native Hawaiians.[B]. Program: National School Lunch Program; Summary of selected program goals[A]: * Safeguard the health and well-being of the nation's children; * Encourage the domestic consumption of nutritious agricultural commodities and other foods. Program: Nutrition Assistance for Puerto Rico; Summary of selected program goals[A]: * Fund nutrition assistance programs for needy people. Program: School Breakfast Program; Summary of selected program goals[A]: * Safeguard the health and well-being of the nation's children; * Encourage the domestic consumption of agricultural and other foods by assisting states to more effectively meet the nutritional needs of children; * Assist the states and the Department of Defense to initiate, maintain, or expand nonprofit breakfast programs in all schools that apply for assistance and agree to carry out a nonprofit breakfast program. Program: Seniors Farmers' Market Nutrition Program; Summary of selected program goals[A]: * Provide fresh, nutritious, unprepared produce to low-income seniors from farmers' markets and roadside stands, and community supported agriculture; * Increase the consumption of agricultural commodities; * Expand or aid the expansion of farmers' markets, roadside stands, and community supported agriculture programs; * Develop or aid in the development of new farmers' markets, roadside stands, and community supported agriculture programs. Program: Special Milk Program; Summary of selected program goals[A]: * Encourage consumption of fluid milk by U.S. children in nonprofit schools, high school grade and under, that don't participate in federal meal service programs; * Encourage consumption of fluid milk by U.S. children in nonprofit institutions devoted to the care and training of children, such as nursery schools and child care centers, that don't participate in federal meal service programs; * Safeguard the health and well-being of the nation's children; * Encourage the domestic consumption of agricultural and other foods by assisting states to more effectively meet the nutritional needs of children. Program: Summer Food Service Program; Summary of selected program goals[A]: * Provide food service to children from needy areas during periods when area schools are closed for vacation; * Assist states to initiate and maintain nonprofit food service programs for children in service institutions. Program: SNAP; Summary of selected program goals[A]: * Raise the level of nutrition among low-income households; * Alleviate hunger and malnutrition in low-income households; * Increase food purchasing power for eligible households; * Strengthen the U.S. agricultural sector; * More orderly marketing and distribution of food; * Permit low-income households to obtain a more nutritious diet through normal channels of trade. Program: The Emergency Food Assistance Program; Summary of selected program goals[A]: * Make maximum use of the nation's agricultural abundance; * Expand and improve the domestic distribution of price-supported commodities; * Make excess agricultural commodities available without charge, for use by eligible recipient agencies for food assistance. Program: WIC; Summary of selected program goals[A]: * Improve the mental and physical health of low-income pregnant, postpartum, and breastfeeding women, infants, and young children; * Prevent the occurrence of health problems, including drug abuse, and improve the health status of the target population; * Provide supplemental foods and nutrition education to target population. Program: WIC Farmers' Market Nutrition Program; Summary of selected program goals[A]: * Provide fresh nutritious unprepared foods from farmers' markets to women, infants, and children at nutritional risk; * Increase awareness and use of farmers' markets and sales at such markets. Source: GAO, presentation based on review of federal legislation and regulations and discussions with agency officials. [A] Each federal food and nutrition assistance program has its own set of program goals that were generally established in legislation or regulation. Program goals were compiled based on our review of federal statutes, regulations, or discussions with agency officials. Program goals were not always formally identified as program goals in the statutes or regulations, and in those cases we analyzed language from the statutes or regulations that we determined closely approximated program goals. While we determined that this list of program goals was sufficient for purposes of this report, we do not consider it a comprehensive list of all of the applicable goals for each program. [B] Officials at Administration on Aging stated that the goals of Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services are the same as those of the Elderly Nutrition Program: Home-Delivered and Congregate Nutrition Services. [End of table] [End of section] Appendix IV: Comments from the Department of Health and Human Services: Department Of Health & Human Services: Office Of The Secretary: Assistant Secretary for Legislation: Washington, DC 20201: March 15, 2010: Kay Brown, Director: Education, Workforce, and Income Security Issues: U.S. Government Accountability Office: 441 G Street N.W. Washington, DC 20548: Dear Ms. Brown: Enclosed are comments on the U.S. Government Accountability Office's (GAO) report entitled: "Domestic Food Assistance: Complex System Benefits Millions but Additional Efforts Could Address Potential Inefficiency and Overlap among Smaller Programs" (GAO-I0-346). The Department appreciates the opportunity to review this report before its publication. Sincerely, Signed by: Andrea Palm: Acting Assistant Secretary for Legislation: Enclosure: [End of letter] General Comments Of The Department Of Health And Human Services (HHS) On The U.S. Government Accountability Office's (GAO) Draft Report; Domestic F000 Assistance: Complex System Benefits Mullions Out Additional Efforts Could Address Potential Inefficiency and Overlap Among Smaller Programs" (GA0-10-346): The Department agrees with the GAO finding that the Elderly Nutrition Programs, also known as the Older Americans Act Congregate and Home Delivered Nutrition Services, directly address critical program goals. These programs increase the needed socialization of older adults and have been found to have a positive effect on food security. DIMS also agrees that these programs improve participants' dietary and nutrient intake—an outcome related to the program's goal of promoting the health and well being of older individuals by assisting such individuals to gain access to nutrition and other disease prevention and health promotion services to delay the onset of adverse health conditions resulting from poor nutritional health or sedentary behavior. We also agree that federal programs should-aim to achieve the greatest efficiency, effectiveness and reduction of duplication and overlap. Data from national surveys of elderly clients also show that the Nutrition Services are effectively helping seniors to improve their nutritional intake and remain at home. For example, 78 percent of congregate and 85 percent of home-delivered meal recipients say they pat healthier meals due to the programs, and 62 percent of congregate add 93 percent of home-delivered meal recipients say that the Meals enabled them to continue living in their own homes. These meals are especially critical for the survival of the 59 percent of congregate and 63 percent of home delivered recipients who report these meals as the only or the majority of their food intake for the day. This latter point is extremely important. For those individuals who count on these meals as the only or major portion of their food intake, it is also crucial to assist them in accessing other benefits that may enable them to remain healthy and independent, e.g. SNAP: Older Americans Act Nutrition Services programs are not duplicative of the Department of Agriculture's programs, but rather complementary: providing meals, rather than the means to obtain groceries. This is particularly important for functionally impaired populations that are unable to either grocery shop or prepare meals for themselves and rely on home-delivered meals. The Older Americans Act Congregate and Home Delivered meals programs are not entitlement programs nor are program participants means tested for eligibility. These programs are part of a comprehensive home and community based system designed to help older adults remain independent in their own homes and communities. As a result, eligibility and application procedures are different and do not overlap with United States Department of Agriculture procedures. The methodology used by GAO, reviewing only studies published through academic research, may be optimal for understanding the outcomes and impacts of large food assistance programs. It must be noted as GAO has stated that other, smaller programs, e.g., administered through American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services, are indeed very small and may not be of sufficient scope or interest to attract this level of scholarly rigor. This does not diminish the importance or effectiveness of these services, particularly since they are closely modeled upon the effective Congregate and Home-Delivered Nutrition Service Programs. These programs will continue to undergo program evaluation of effectiveness and continual quality improvement. The Department recognizes the critical importance of addressing the nutritional needs of older adults. The Administration on Aging (AoA), through the Aging Services Network of 56 State Units on Aging, 629 Area Agencies on Aging, 244 Tribal Organizations and thousands of providers, offers services and supports. Authorized under the Older Americans Act. These dedicated professionals provide home delivered and congregate setting meals to over 2.5 million older adults each year. Congregate Nutrition services, established in 1972, and Home-Delivered Nutrition Services, established in 1978, provide meals and related services to older adults in a variety of settings (including congregate facilities such as senior centers) and home-delivery to seniors that are homebound due to illness, disability, or geographic isolation. The meals provided through these programs are based on the best science fulfilling the standards set by the Dietary Guidelines for Americans and provide a minimum of 33 percent of the Dietary Reference Intake, as established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences. Nutrition Services help millions of older adults receive the meals they need to stay healthy and decrease their risk of disability. Studies have found that half of all persons age 85 and over are in need of assistance with instrumental activities including obtaining and preparing food and nutrition programs help address their needs. Serving Elders at Risk, a national evaluation of nutrition program clients, found that nutrition service recipients are older, poorer, more likely to live alone, more likely to be minorities, are sicker, in poorer health, in poorer nutritional status, more functionally impaired, and at higher nutritional risk than those in the general population. These programs are of such high need and importance that the American Recovery and Reinvestment Act of 2069 (Recovery Act) provided $100 million to supplement AoA's existing nutrition, services programs — Congregate, Home-Delivered, and Nutrition Services for Native Americans. These Recovery Act funds will help more than 350,000 seniors remain healthy and independent in their communities by providing over 14 million meals. HHS has met with the Department of Agriculture on numerous occasions to discuss our common aims of easing access and providing the highest quality of service. The Department will strenuously continue its work to best assure that older adults and their family caregivers receive the services and supports, including Nutrition Services, that help maintain their independence, health and well-being. [End of section] Appendix V: GAO Contact and Staff Acknowledgments: GAO Contact: Kay Brown, (202) 512-7215 or brownke@gao.gov: Staff Acknowledgments: In addition to the contact named above, Kathryn Larin, Assistant Director; Cheri Harrington, Analyst-in-Charge; Jacques Arsenault; David Barish; Nancy Cosentino; Sara Edmondson; Alex Galuten; Charlene Johnson; Kirsten Lauber; Jean McSween; Mimi Nguyen; Susan Offutt; Jessica Orr; Rhiannon Patterson; Catherine Roark; Nyree Ryder Tee; Gregory Whitney; and Charles Willson made significant contributions to this report. [End of section] Related Products: School Meal Programs: Experiences of the States and Districts That Eliminated Reduced-price Fees. [hyperlink, http://www.gao.gov/products/GAO-09-584]. Washington, D.C.: July 17, 2009. Food Stamp Program: Options for Delivering Financial Incentives to Participants for Purchasing Targeted Foods. [hyperlink, http://www.gao.gov/products/GAO-08-415]. Washington, D.C.: July 30, 2008. Department of Agriculture, Food and Nutrition Service: Special Supplemental Nutrition Program for Women, Infants and Children (WIC): Revisions in the WIC Food Packages. [hyperlink, http://www.gao.gov/products/GAO-08-358R]. Washington, D.C.: December 17, 2007. Nutrition Education: USDA Provides Services through Multiple Programs, but Stronger Linkages among Efforts Are Needed. [hyperlink, http://www.gao.gov/products/GAO-04-528]. Washington, D.C.: April 27, 2004. Federal Food Safety and Security System: Fundamental Restructuring Is Needed to Address Fragmentation and Overlap. [hyperlink, http://www.gao.gov/products/GAO-04-588T]. Washington, D.C.: March 30, 2004. Food Stamp Program: Steps Have Been Taken to Increase Participation of Working Families, but Better Tracking of Efforts Is Needed. [hyperlink, http://www.gao.gov/products/GAO-04-346]. Washington, D.C.: March 5, 2004. School Lunch Program: Efforts Needed to Improve Nutrition and Encourage Healthy Eating. [hyperlink, http://www.gao.gov/products/GAO-03-506]. Washington, D.C.: May 9, 2003. Fruits and Vegetables: Enhanced Federal Efforts to Increase Consumption Could Yield Health Benefits for Americans. [hyperlink, http://www.gao.gov/products/GAO-02-657]. Washington, D.C.: July 25, 2002. Food Stamp Program: States' Use of Options and Waivers to Improve Program Administration and Promote Access. [hyperlink, http://www.gao.gov/products/GAO-02-409]. Washington, D.C.: February 22, 2002. Means-Tested Programs: Determining Financial Eligibility Is Cumbersome and Can be Simplified. [hyperlink, http://www.gao.gov/products/GAO-02-58]. Washington, D.C.: November 2, 2001. Food Assistance: Research Provides Limited Information on the Effectiveness of Specific WIC Nutrition Services. [hyperlink, http://www.gao.gov/products/GAO-01-442]. Washington, D.C.: March 30, 2001. Food Assistance: Performance Measures for Assessing Three WIC Services. [hyperlink, http://www.gao.gov/products/GAO-01-339]. Washington, D.C.: February 28, 2001. Title III, Older Americans Act: Carryover Funds Are Not Creating a Serious Meal Service Problem Nationwide. [hyperlink, http://www.gao.gov/products/GAO-01-211]. Washington, D.C.: January 9, 2001. Food Assistance: Options for Improving Nutrition for Older Americans. [hyperlink, http://www.gao.gov/products/GAO/RCED-00-238]. Washington, D.C.: August 17, 2000. Early Education and Care: Overlap Indicates Need to Assess Crosscutting Programs. [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-78]. Washington, D.C.: April 28, 2000. Managing for Results: Barriers to Interagency Coordination. [hyperlink, http://www.gao.gov/products/GAO/GGD-00-106]. Washington, D.C.: March 29, 2000. Welfare Programs: Opportunities to Consolidate and Increase Program Efficiencies, [hyperlink, http://www.gao.gov/products/GAO/HEHS-95-139]. Washington, D.C.: May 31, 1995. Food Assistance Programs. [hyperlink, http://www.gao.gov/products/GAO/RCED-95-115R]. Washington, D.C.: February 28, 1995. Food Assistance: USDA's Multiprogram Approach. [hyperlink, http://www.gao.gov/products/GAO/RCED-94-33]. Washington, D.C.: November 24, 1993. Early Intervention: Federal Investments Like WIC Can Produce Savings. [hyperlink, http://www.gao.gov/products/GAO/HRD-92-18]. Washington, D.C.: April 7, 1992: Food Assistance Programs: Recipient and Expert Views on Food Assistance at Four Indian Reservations. [hyperlink, http://www.gao.gov/products/GAO/RCED-90-152]. Washington, D.C.: June 18, 1990. Food Assistance Programs: Nutritional Adequacy of Primary Food Programs on Four Indian Reservations. [hyperlink, http://www.gao.gov/products/GAO/RCED-89-177]. Washington, D.C.: September 29, 1989. [End of section] Footnotes: [1] On October 1, 2008, the Food Stamp Program changed its name to the Supplemental Nutrition Assistance Program (SNAP). In this report, we discuss information related to both the Food Stamp Program and SNAP; however, for simplicity, we generally refer to the program as SNAP. [2] Preliminary data from U.S. Department of Agriculture. [3] We did not include programs that are permitted to spend some portion of their federal funding on food or nutrition assistance but chose not to, nor did we include programs that provided only nutrition education. [4] The Catalog of Federal Domestic Assistance is a database of all federal programs available to state and local governments, including the District of Columbia; federally-recognized Indian tribal governments; territories (and possessions) of the United States; domestic public, quasi-public, and private for profit and nonprofit organizations and institutions; specialized groups; and individuals. [5] Census Bureau began measuring food security in 1995 using the nationally representative CPS. The survey asks individuals 10 questions (18 questions are asked if the household contains children 18 years of age or younger) about behaviors or conditions known to characterize households having difficulty meeting basic food needs. The answers to the survey questions determine the food security status of each household, and collectively, these answers allow USDA to monitor and track changes in food insecurity among U.S. households. Food security data representing 2008 are the most current available. [6] The CFFR reports federal government expenditures or obligations in state, county, and subcounty areas of the United States, as well as the District of Columbia and U.S. outlying areas. Federal government agencies provide data for this report from their existing reporting systems. The CFFR is compiled by the U.S. Census Bureau. [7] In 2004 the Economic Research Service, with Abt Associates Inc., published a large scale literature review: Effects of Food Assistance and Nutrition Programs on Nutrition and Health. This report discusses a comprehensive review of studies published between 1973 and 2002 related to the impact of USDA’s domestic food and nutrition assistance programs on participants’ nutrition and health outcomes. While many of the studies within the Economic Research Service review have limitations (for example, limitations related to research design and the potential for selection bias), we found the literature review to be reliable and appropriate for our use. [8] According to the Committee on National Statistics at the National Academies, hunger is a complex concept with multiple definitions and is difficult to measure. It is based not only on resource constraints but also has physiological and socioeconomic aspects. To appropriately measure hunger, the panel believed that the term would need to be clearly defined and more detailed, and extensive information on the physiological experiences of individuals would need to be collected. In contrast, the panel argued the low food security definition, compared to hunger, is more straightforward. Low and very low food security simply describe the uncertainty or inability of a household to acquire enough food because the household lacks resources or money— it does not address the individual, physiological, or socioeconomic aspects of not having enough food. CPS Food Security Supplement data represent households, not individuals. The panel reported that while hunger may result from food insecurity, hunger is experienced by individuals and thus is not directly measured by the questions in the CPS. USDA concurred with the panel’s recommendation. [9] Prior to the recommendations released by Committee on National Statistics in 2006, USDA used the terms “food insecurity without hunger” and “food insecurity with hunger” to describe the severity of a household’s food insecurity. After 2006 USDA replaced these terms with “low food security” and “very low food security” to describe the extent to which a household was food insecure. [10] Examples of these survey questions include, (1) “‘We worried whether our food would run out before we got money to buy more.’ Was that often, sometimes, or never true for you in the last 12 months?”; (2) “’The food that we bought just didn’t last and we didn’t have money to get more.’ Was that often, sometimes, or never true for you in the last 12 months?”; and (3) “’We couldn’t afford to eat balanced meals.’ Was that often, sometimes, or never true for you in the last 12 months?” [11] Survey respondents also reported the amounts their households had spent on food and whether they had used public or private food and nutrition assistance programs. [12] Children in these households are classified as having low or very low food security depending on the number of times respondents answer yes to questions indicating food insecure conditions among children. [13] According to USDA, the Food Stamp Act of 1977 eliminated the requirement that participants make some payment to receive food stamp benefits. [14] See appendix I for a description of how we identified these programs. [15] USDA, Economic Research Service, Effects of Food Assistance and Nutrition Programs on Nutrition and Health, Volume 4, Executive Summary of the Literature Review. Food Assistance and Nutrition Research Report No. 19-4 (Washington, D.C., November 2004). [16] Mark Nord, Margaret Andrews, and Steven Carlson. Household Food Security in the United States, 2008/ERR-83, Economic Research Service, USDA (November 2009). [17] Food insecurity prevalence rates are sample-based estimates. All food insecurity rates presented in this report are statistically significant (different than zero) at the 90 percent confidence level and rates for different subpopulations are presented only where there are statistically significant differences between these populations. For more information about the confidence intervals around the food insecurity rates, see appendix II. [18] Single parent families and minorities have higher than average rates of poverty, which may explain some of the relatively high rates of food insecurity in these households. In 2008, according to Census Bureau estimates, 37.2 percent of households with children headed by a single woman were poor and 17.6 percent of households with children headed by a single man were poor, compared to 7.5 percent of households with children headed by a married couple. Among persons of Hispanic origin, 23.2 percent were poor in 2008, as were 24.6 percent of black persons, compared to an overall poverty rate of 13.2 percent and an 11.3 percent poverty rate among white persons. GAO did not conduct an analysis of the extent to which differences in income levels explain differences in food insecurity rates among demographic groups. [19] The federal poverty line varies depending on the number of members in a family. For example, the poverty line for a family of four with two children was $21,834 in 2008. [20] Unofficial special tabulations provide to us by the Economic Research Service. [21] According to a GAO search on the Office of Management and Budget’s Web site (www.earmarks.omb.gov), Congress directed approximately $4.5 million to food banks in fiscal year 2008 to support the construction, maintenance, or purchase of facilities and equipment. [22] Since WIC is not an entitlement program, its funding is determined annually through the congressional appropriations process. In recent years, WIC has been funded at levels that allow the program to serve all or nearly all applicants who apply and meet the eligibility requirements. [23] Federal policy changes may have contributed to the changes in SNAP spending between 1996 and 2004. For example, the total number of people receiving SNAP fell after passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 when participation in the program was “de-linked” from participation in Temporary Assistance for Needy Families (TANF). Since 2000, however, states have implemented policies to ensure that those eligible for SNAP continue to receive benefits when they leave TANF. Also the Food Stamp Reauthorization Act of 2002 expanded program access by, for example, restoring eligibility for certain qualified alien populations and adjusting the standard deduction. [24] According to USDA officials, CFFR data does not represent the full funding amount for the Child and Adult Care Food Program in fiscal years 2000 and 2001. [25] The number of households participating in SNAP also increased by about 15 percent from 1995 to 2008. [26] We conducted analyses of the correlation between year-to-year changes in SNAP expenditures with year-to-year changes in the poverty rate and year-to-year changes in the unemployment rate from 1995 through 2008. The correlation between changes in SNAP expenditures and changes in the poverty rate was statistically significant at the 5 percent level, while the correlation between changes in SNAP expenditures and changes in the unemployment rate was not statistically significant. [27] From June 2008 to June 2009 the average SNAP monthly benefit per person increased by 32 percent. Specifically, the average monthly benefit increased from about $101 in December 2007 to about $133 in September 2009, with large increases enabled by changes through the 2008 Farm Bill and through the Recovery Act. The 2008 Farm Bill instituted several changes to SNAP, including an increase in the minimum benefit and standard deduction, elimination of retirement and education accounts counting as financial resources, eliminating certain combat pay as income when determining eligibility, and deduction of the full cost associated with child care. The Recovery Act temporarily increased SNAP’s maximum benefit allotments of participants, eased eligibility requirements for childless adults without jobs, and provided additional funding to state agencies responsible for administering SNAP. [28] Congress enacted the 2008 Farm Bill in May 2008 to provide for the continuation of agricultural programs through fiscal year 2012, and for other purposes. [29] Congress enacted the American Recovery and Reinvestment Act of 2009 in February 2009. The goals of the act include, creating jobs and promoting economic recovery; to assisting those most impacted by the recession; providing investments needed to increase economic efficiency by pursuing technological advances in science and health; investing in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits; and stabilizing state and local government budgets. [30] Recovery Act funds dedicated to food assistance programs were not included in table 3 of this report because this review does not include program obligations or outlays from fiscal year 2009. [31] SNAP and the National School Lunch Program each make periodic adjustments in their benefit or reimbursement amounts, which are based in part on changes in the cost of food as reflected in the thrifty food plan and the Consumer Price Index (CPI) for food away from home, respectively. [32] The research we reviewed, as well as the research ERS, reviewed does not, for the most part, specifically examine whether the programs meet their legislative or programmatic goals. To provide information on the effects of these programs, we established linkages between these goals and the outcomes examined in the literature. Assessing whether the benefits of program participation outweigh the programs’ costs is beyond the scope of this report. See appendix I for more information about these linkages. [33] Our current review did not look at the effectiveness of nutrition education programs or the nutrition education components of programs. For information on USDA’s nutrition education efforts, see GAO, Nutrition Education: USDA Provides Services through Multiple Programs, but Stronger Linkages among Efforts Are Needed, [hyperlink, http://www.gao.gov/products/GAO-04-528] (Washington, D.C.: Apr. 27, 2004). [34] Some positive effects on dietary intake were found for pregnant women. The results of studies on dietary intake among children participating in WIC were unclear. [35] While the literature on WIC’s effects on birth weight and other birth outcomes suggests the program has a number of important positive effects, the actual size of these effects is not easy to determine. Some researchers believe that WIC’s effect on these outcomes is actually quite small. For example, the authors of Reassessing the WIC Effect: Evidence from the Pregnancy Nutrition Surveillance System conclude that WIC “may work to improve birth outcomes, but on fewer margins and with less impact than has been claimed by policy analysts and advocates.” [36] This goal includes language specifically related to preventing the occurrence of health problems, including drug abuse; however, none of the literature looked specifically at reductions in the use of illegal drugs. [37] None of the research we reviewed examined effects related to the School Breakfast Program goal of assisting the states and the Department of Defense initiate, maintain, or expand nonprofit breakfast programs in all schools that apply for assistance and agree to carry out a nonprofit breakfast program. [38] The Healthy Eating Index is a measure of diet quality that assesses conformance to federal dietary guidance. USDA’s primary use of the HEI is to monitor the diet quality of the U.S. population and the low-income subpopulation. [39] The School Breakfast Pilot Program provided free universal breakfasts and the study was designed to evaluate the effects of this practice. Its results are therefore only suggestive of the effects of the School Breakfast Program. McLaughlin, J., L. Bernstein, M.K. Crepinsek,. Evaluation of the School Breakfast Program Pilot Project: Findings from the First Year of Implementation, Food and Nutrition Service, USDA (2002). [40] There is relatively limited research that looks at this outcome and much of the research that exists has methodological limitations. However, a study by D.W. Schanzenbach, Do School Lunches Contribute to Childhood Obesity?, found that, on average, students eating a school lunch consumed an extra 40 calories a day when compared to “brown- baggers.” School lunch eaters were more likely to be obese or overweight and have higher body mass index scores by 3rd and 5th grade than brown-baggers. Other studies have found no effect on body mass index or weight of participants of the National School Lunch Program, and some have found that for some populations, participation reduced the likelihood of these negative outcomes. [41] A number of USDA programs have similar goals related to supporting the agricultural sector, making use of excess agricultural produce, and improving the food distribution system. [42] School nutrition programs include the National School Lunch Program, the School Breakfast Program, the Special Milk Program, and the Summer Food Service Program. [43] When calculating the total increase in food expenditures generated by these programs, the Economic Research Service subtracted out the value of food that would have been consumed anyway in the absence of the programs. [44] Hanson, Kenneth, Importance of Child Nutrition Programs to Agriculture, Food Assistance and Nutrition Research Report Number 34- 12, Economic Research Service, USDA (Washington, D.C., July 2003). [45] Furthermore, these increases have been found to be greater than that which would occur if the same dollar value of benefits were provided as unrestricted cash grants. [46] Two of the three identified studies reviewed found that the program increased the level of socialization among participants. One study found that use of program sponsored shopping assistance was associated with being extremely isolated. [47] Some of the research on the program focuses on pilot or demonstration projects which may not reflect the way the program currently operates nationwide and is therefore only suggestive of possible effects. For example, one of the two studies that suggest the program has a positive effect on food security was of a pilot program that provided two meals a day rather than the traditional one meal. [48] Nader S. Kabbani and Myra Yazbeck Kmeid, “The Role of Food Assistance in Helping Food Insecure Households Escape Hunger,” Review of Agricultural Economics, vol. 27 No. 3. [49] Nord, M. and Golla, A.M. Does SNAP Decrease Food Insecurity? Untangling the Self-Selection Effect, Economic Research Service, USDA (October 2009). [50] This paper matched food insecurity survey data for households for several months before and after they began receiving SNAP benefits. [51] Nader S. Kabbani and Myra Yazbeck Kmeid, “The Role of Food Assistance in Helping Food Insecure Households Escape Hunger,” Review of Agricultural Economics, vol. 27 No. 3. [52] Wilde, P. and Nord, M. “The Effect of Food Stamps on Food Security: A Panel Data Approach.” Review of Agricultural Economics, vol. 27 No. 3. [53] Only one study was identified that looked at this outcome and its results do not provide clear evidence on the program’s effect. (Black, M.D. Cutts, D. Frank, Special Supplemental Nutrition Program for Women, Infants, and Children Participation and Infants’ Growth and Health: A Multisite Surveillance Study, Pediatrics 114:169-76, 2004.) [54] Only one study examined the program’s effects on food security. Certain statistical models employed by the authors suggest the availability of the School Breakfast Program reduces the risk of marginal food security, but the results on the program’s effects on food insecurity were not statistically significant. The authors stated their belief that selection bias is resulting in an underestimation of the program’s effects. [Bartfeld, Judi, Kim, Myoung, Hee Ryu, Jeong, and Ahn, Hong-Min, The School Breakfast Program: Participation and Impacts,. Economic Research Service, USDA (July 2009).] One study of the School Breakfast Pilot Program also addressed the program’s effects on food security, but found no significant results. [55] The study on the Child and Adult Care Food Program found that meals and snacks served at participating centers and homes scored significantly higher than nonparticipating centers on nutrient content, nutrient density, and food quality and variety. [56] Nord, M., and Romig, K. “Hunger in the Summer: Seasonal Food Insecurity and the National School Lunch and Summer Food Service Programs,” Journal of Children and Poverty Vol. 12, issue 2 (September 2006). This study found that in states with large summer National School Lunch and Summer Food Service programs, summer lunches provided by the these two programs had a considerable effect in lessening the differences in the prevalence of hunger in households with school-aged children between the times when school was in session and the children received meals through the National School Lunch Program and during the summer months when children received meals through either the National School Lunch Program or the Summer Food Service Program compared with these households in states with smaller summer feeding programs. [57] This study [Evaluation of the Commodity Supplemental Food Program: Final Report-Health and Nutrition Impacts of Three Local Projects Mahony Monrad, D., S.H. Pelavin, R.F. Baker, Food and Nutrition Service, USDA (1982)] examined gestational age, birth weight and birth weight adjusted for gestational age. The study found the program had positive and statistically significant effects on these birth outcomes. However, improving birth outcomes is not directly related to the program’s goal. In addition, the study is dated and some aspects of the authors’ methodology are unclear. A second study was identified that looked at food security of elderly program participants, but not enough information on the study’s methodology was available to assess the strength of its findings and it was therefore excluded from our analysis. [58] Developed in 2002, the PART was a governmentwide evaluation tool used to assess and improve the performance of federal programs. According to the Office of Management Budget: “A PART review helps identify a program’s strengths and weaknesses to inform funding and management decisions aimed at making the program more effective. The PART therefore looks at all factors that affect and reflect program performance including program purpose and design; performance measurement, evaluations, and strategic planning; program management; and program results. Because the PART includes a consistent series of analytical questions, it allows programs to show improvements over time, and allows comparisons between similar programs.” Possible ratings under PART included: effective, moderately effective, adequate, ineffective, and results not demonstrated. [59] Five of the programs in this review that have been the subject of more academic study, as well as the Administration on Aging as a whole, have also been rated by PART. WIC and the Administration on Aging received “effective” ratings; the National School Lunch Program, the School Breakfast Program, and SNAP received “moderately effective” ratings; and Nutrition Assistance for Puerto Rico received an “adequate” rating. [60] More than 100,000 adults also received meals through this program on a daily basis in fiscal year 2008. [61] In addition to meeting specified income and asset requirements, SNAP recipients are also subject to other requirements, such as certain work and immigration status requirements. [62] Some of these low-income, food insecure households were not eligible for any of the programs and a majority were not eligible for child nutrition programs because there were no children in the household. [63] See GAO, Early Education and Care: Overlap Indicates Need to Assess Crosscutting Programs, [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-78] (Washington, D.C.: Apr. 28, 2000). [64] See GAO, Means-Tested Programs: Determining Financial Eligibility Is Cumbersome and Can be Simplified, [hyperlink, http://www.gao.gov/products/GAO-02-58] (Nov. 2, 2001); Managing for Results: Barriers to Interagency Coordination, [hyperlink, http://www.gao.gov/products/GAO/GGD-00-106] (Washington, D.C.: Mar. 29, 2000); and Welfare Programs: Opportunities to Consolidate and Increase Program Efficiencies, [hyperlink, http://www.gao.gov/products/GAO/HEHS-95-139] (Washington, D.C.: May 31, 1995). [65] The elimination of the Commodity Supplemental Food Program was proposed by the administration’s budget proposals in three different fiscal years: 2007, 2008, and 2009. [66] [hyperlink, http://www.gao.gov/products/GAO/HEHS-95-139]. [67] See GAO, Food Assistance: USDA’s Multiprogram Approach, [hyperlink, http://www.gao.gov/products/GAO/RCED-94-33] (Washington, D.C.: Nov. 24, 1993). [68] Examples of nutrition education programs include the Team Nutrition Initiative and Expanded Food and Nutrition Education Program. In addition to providing nutrition assistance, WIC also has significant nutrition education components. Other programs—such as SNAP, the National School Lunch Program, and the Child and Adult Care Food Program—also have nutrition education components but primarily provide food assistance. [69] See GAO, Nutrition Education: USDA Provides Services through Multiple Programs, but Stronger Linkages among Efforts Are Needed, [hyperlink, http://www.gao.gov/products/GAO-04-528] (Washington, D.C.: Apr. 27, 2004). [70] However, it is unclear whether elements of USDA nutrition education programs outside of the Food and Nutrition Service have explicit coordination strategies. [71] CFDA is a database of all federal programs available to state and local governments, including the District of Columbia; federally recognized Indian tribal governments; territories (and possessions) of the United States; domestic public, quasi-public, and private for profit and nonprofit organizations and institutions; specialized groups; and individuals. [72] CFDA states that "A 'federal domestic assistance program' may in practice be called a program, an activity, a service, a project, a process, or some other name, regardless of whether it is identified as a separate program by statute or regulations." The CFDA further notes that "'assistance' or 'benefits' refers to the transfer of money, property, services, or anything of value, the principal purpose of which is to accomplish a public purpose of support or stimulation authorized by federal statute." [73] See GAO, Nutrition Education: USDA Provides Services through Multiple Programs, but Stronger Linkages among Efforts Are Needed, [hyperlink, http://www.gao.gov/products/GAO-04-528] (Washington, D.C.: Apr. 27, 2004). [74] CMS officials told us that they would not be confirming the exclusion of their program Medicare Medical Nutrition Therapy. [75] The CFFR reports federal government expenditures or obligations in state, county, and subcounty areas of the United States, as well as the District of Columbia and U.S. outlying areas. Federal government agencies provide data for this report from their existing reporting systems. The CFFR is compiled by the Bureau of the Census. [76] Program goals were not always specifically identified as such in the statutes or regulations, and in those cases we analyzed language from the statutes or regulations that we determined closely approximated program goals. [77] For programs on which limited research was identified, these criteria were relaxed. [78] For more information on the design factor used in calculating these standard errors see: Mark Nord, Margaret Andrews, and Steven Carlson, Household Food Security in the United States, 2008 ERR-83, Economic Research Service, USDA (November 2009). [End of section] GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO's commitment to good government is reflected in its core values of accountability, integrity, and reliability. 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