# Food and Housing Insecurity, Stress, and Health Care Use After Medicaid Expanded Services Program

## TL;DR

A study in Massachusetts found no significant short-term improvements in food or housing insecurity, diet, stress, or health care use among Medicaid beneficiaries participating in a new program.

## Contribution

This study evaluates the impact of a Medicaid program addressing social needs, finding no significant short-term benefits in key outcomes.

## Key findings

- FSP participation was not associated with changes in food or housing insecurity, diet, stress, or health care use after one year.
- Interviews revealed mixed participant experiences, including both benefits and ongoing challenges.
- No differences were observed in depression or anxiety symptoms between FSP and non-FSP participants.

## Abstract

This cohort study assesses the social, behavioral, and clinical outcomes associated with participation in the Massachusetts Medicaid Flexible Services program.

What changes in social needs, diet, stress, and acute health care use are associated with implementation of the Massachusetts Medicaid Flexible Services program (FSP) addressing food and housing insecurity?

In a cohort study of 153 FSP participant episodes and 1495 non–FSP participant episodes among adult Medicaid beneficiaries, there were no differences in food or housing insecurity, dietary quality, stress, or health care use between these 2 groups at 1 year. In interviews, participants reported experiencing a range of positive, neutral, and negative changes following FSP.

The findings suggest that FSP participation was not associated with positive changes in social needs, diet, stress, or health care use within the first year, although some participants reported benefits.

Massachusetts implemented a Flexible Services program (FSP) under a Medicaid Section 1115 waiver to address food and housing insecurity for accountable care organization (ACO) beneficiaries. Little is known about the social, behavioral, and clinical outcomes associated with Medicaid social needs interventions.

To compare 1-year changes in food and housing insecurity, diet, stress, and acute health care use between individuals who participated in the Massachusetts FSP and those who did not.

This prospective cohort study enrolled adult Medicaid beneficiaries from 5 community health centers in 1 eastern Massachusetts ACO from December 2019 through December 2020. Participants who were enrolled in FSP were compared with propensity score–weighted FSP-eligible study participants who were not enrolled in FSP (hereafter non–FSP participants). All FSP participants completed surveys and dietary recalls at enrollment and then annually for 3 years. In-depth interviews were conducted with 27 FSP participants. All data analyses were conducted from August 2024 to April 2025.

Enrollment in FSP.

Primary outcomes were 1-year changes in food and housing insecurity, stress, dietary quality, and acute health care use. Secondary outcomes were changes in depression and anxiety symptoms. Annual surveys measured food insecurity (10-item US Department of Agriculture Food Security Scale Module; score range: 0-10, with ≥3 indicating food insecurity), housing insecurity (questions regarding current housing, moving ≥2 times in past year, and worrying about losing housing), and stress (the 10-item Perceived Stress Scale [PSS]; score range: 0-40, with ≥14 indicating moderate to severe stress). Diet quality was measured with the Healthy Eating Index-2020 (HEI-2020; score range: 0-100, with higher scores indicating healthier diet quality). Acute health care use included annual emergency department (ED) visits and acute hospitalizations.

There were 153 FSP participant episodes (representing 153 study participants; mean [SD] age, 43.6 [10.8] years; 129 females [84.3%]) and 1495 non–FSP participant episodes (representing 610 unique study participants; mean (SD) age 43.2 (11.2) years; 464 females [76.1%]) in the sample. Before FSP enrollment, 111 (72.5%) had food insecurity, 68 (44.4%) had housing insecurity, and 55 (35.9%) had both. There were no differences between the FSP and non-FSP groups in changes in proportion of individuals with food insecurity (difference in change, 4.96%; 95% CI, −3.13% to 13.05%) or housing insecurity (difference in change, 2.75%; 95% CI: −5.39% to 10.88%). There were no differences between groups in HEI-2020 scores, PSS scores, or acute health care use. Participant interviews reflected a range of experiences associated with FSP, from favorable changes in social needs and health to persistent challenges related to cost of food and limited housing availability.

This study of adult Medicaid beneficiaries found that FSP was not associated with short-term favorable changes in food or housing insecurity, diet, stress, or acute health care use. In interviews, FSP participants highlighted both the benefits and challenges of addressing social needs through such health system interventions.