By Leighton Ku, Douglas J. Besharov and Peter Germanis
This article originally appeared in The Public Interest, Spring 1999.
In their critical review of the Women, Infants and Children (WIC)
nutrition program ("Is WIC As Good As They Say," The Public Interest, No. 134,
Winter 1999), Douglas J. Besharov and Peter Germanis conclude that WIC is
less effective than commonly believed and that the research evidence is flawed.
They suggest various ways to restructure the program in fashions more to their
liking, although they offer little evidence that their proposals are feasible or
would be more effective. I appreciate the spirit of constructive criticism
brought by Besharov and Germanis, but I disagree with many of their conclusions.
Let me begin by observing that Besharov and Germanis's article is
incomplete and stilted. Public-health research about the WIC program has been
amazingly fertile. A brief search of scientific papers published in health
journals collected by the National Library of Medicine found more than 200
published studies concerning WIC, and there are other excellent papers in
public-policy or economics journals, as well as unpublished reports. Despite its
relatively small size, WIC has been one of the most thoroughly studied federal
programs. Researchers have investigated WIC's effects on: birth weights, infant
mortality, reductions in Medicaid expenditures, nutrient intakes, children's
cognitive development, immunization rates and use of health services, childhood
anemia, and breastfeeding rates. Many of the most interesting papers are not
rigorous evaluations but reports of field studies or descriptive analyses that
help us look at questions just like those that Besharov and Germanis raise: how
to improve breastfeeding rates and nutritional counseling, and how to use WIC to
improve immunization rates or to coordinate WIC with home-visit programs.
Much of their paper discusses flaws in studies about whether WIC
improves birth outcomes. They note methodological problems, like selection bias
in many of the studies, but fail to note that Jack Metcoff of the University of
Oklahoma and his associates conducted a randomized experiment to determine how
WIC affects pregnant women's birth outcomes. This study, published in 1985,
found that WIC increased birth weights by an average of 91 grams and meets most
of their methodological objections.
Growth in the program since then has made it ethically impossible
to replicate this randomized study, but most subsequent studies, conducted using
a plethora of data sources, statistical methods, and outcome measures, generally
reach the same conclusions-that WIC helps low-income pregnant women bear
heavier, healthier babies. Come on guys, how long do we have to study something
to conclude reasonably that it works? Are you acting like the fringe groups who
wonder whether smoking tobacco really causes lung cancer?
BESHAROV and Germanis also understate the strength of the
evidence. For example, they note that Ray Yip and his colleagues at the Center
for Disease Control (CDC) found that decreasing anemia among WIC participants
could be caused by a secular decline in childhood anemia. What they do not
mention is that the CDC also found that fewer WIC children were anemic between
the time they first entered the program and recertification, usually six months
later. These specific and rapid improvements could not be caused by general
secular changes and almost certainly are due to the iron-fortified foods in the
WIC food package. These clinical findings are consistent with results from the
National WIC Evaluation and those from Donald Rose of the Economic Research
Service of USDA and his associates, indicating that WIC children consumed more
key nutrients, including iron. While there have not been definitive, randomized
studies for children, the research findings are consistent and compelling.
Equally important, WIC can improve children's health by boosting
immunization rates. Because WIC is typically located in health clinics and
serves millions of low-income children, it is well-suited to promote
immunization. Mothers and their young children must regularly come to WIC
clinics to be certified or to get food vouchers. The National WIC Evaluation
found that children participating in WIC were more likely to be immunized than
nonparticipating children. Several recent studies, including two published in
the Journal of the American Medical Association, showed how changes in WIC
program operations can further increase immunization rates. State and local WIC
clinics have also formed partnerships with Vaccines for Children, Medicaid, and
local maternal and child health programs to reinforce preventive health care for
children. By increasing immunizations, WIC can indirectly reduce the incidence
of preventable diseases like measles.
Other aspects of the WIC program have been less thoroughly
studied. But contrary to Besharov and Germanis's assertion that they are
unveiling a secret hidden from the American public, these gaps have been
well-known for a long time and publicly discussed by the General Accounting
Office, the National Academy of Sciences, myself, and fellow researchers like
Barbara Devaney of Mathematica Policy Research. And we have made steady gains in
our understanding of the program; the U.S. Department of Agriculture, which
administers WIC, has long funded research about WIC. Do I wish for more and
better evaluations? Of course. I would love to see more research about the
effects of participation in WIC during childhood and whether the current program
design provides the best package of benefits. However, I realize that rigorous
studies are difficult to design, cost a lot, and take many years to complete.
The fiscal reality is this: Research budgets are limited, and evaluation studies
must compete for resources with other priorities.
WHILE the research evidence about WIC's effectiveness is not
perfect, it is hard to think of any public program with so consistent a body of
positive research findings. Further, the federal government continues to invest
in research to better understand and strengthen the program. No doubt this
strong research record accounts for the program's popularity. But the program
also receives high marks for its design. Steering a middle course between the
problem of entitlements and the inherent vagueness of block grants, WIC is a
federal program that allows for local and state administration. This has
satisfied WIC's state and local managers, allowing them to be creative within a
framework of broadly shared goals and a time-tested program structure.
One good example of state or local innovation is WIC's infant
formula rebates, in which competitive bidding reduces the price of WIC infant
formula. Typically, the rebates amount to 80 percent or more of the price of
formula, collectively saving more than $ 1 billion annually. The rebates began
as state initiatives and have become one of the best examples of the power of
competitive bidding within government. Linking WIC to immunization efforts is
another example of creative local initiatives.
WIC incorporates principles shared by conservatives and liberals.
It seeks to prevent problems, not just cure them. It strives for efficiency and
cost-containment in operations. It fosters family responsibility by teaching
parents how to improve their children's diets, as well as by providing healthy
food directly. It is not an unlimited handout but provides specific benefits
during a critical stage in a child's development. Finally, it permits creative
collaboration between program directors at federal, state, and local levels.
BESHAROV and Germanis suggest that WIC should have even more
flexibility and that paying for additional services by providing fewer people
with food benefits would be the right thing to do. In particular, they propose
that WIC should try home visits for pregnant women, based on a model developed
and tested by David Olds at the University of Colorado. There are indeed many
proven merits to home-visit programs, but I am not sure that paying for the
entire range of home-visit services is WIC's mission. Many other programs are
better suited to financing non-nutrition-related services for pregnant women,
including Healthy Start, Title V Maternal and Child Health Block Grants, Title
XX Social Services Block Grants, and Medicaid. Providing WIC nutrition services
through home visits, in coordination with other programs, is an attractive idea,
but this is already permitted under current program rules.
Flexibility for state and local programs is important but does
not, by itself, guarantee success. The Healthy Start program gives communities
great autonomy to design and implement projects to improve birth outcomes,
including home-visit programs, but preliminary, interim evaluations have been
disappointing. Does it make sense to divert resources from WIC's relatively
well-proven model toward one yielding inconclusive results to date?
Besharov and Germanis apparently believe that WIC provides food to
too many mothers and children. For example, they complain that almost half of
the infants in the country get WIC benefits. What they do not mention is that
there is an alarmingly high level of poverty and near poverty among American
families with young children. Mothers with infants are often unable to work full
time and, even when they work, often have low-wage jobs. To qualify for WIC, a
family of four must generally have an annual income of about $ 30,000 or less,
which most of us would agree is a relatively low income. The main reason that
almost half the nation's infants receive WIC benefits is that, sadly, about half
the babies are in poor and low-income families.
Without WIC, a low-income family would need to spend more than $
1,000 a year to feed its baby and purchase the infant formula and other
fortified foods provided by WIC. Few low-income families can afford to spend
this much on their own. WIC ensures that these babies have nutritious foods
available. In addition, competitive purchasing allows the government to purchase
these foods at a fraction of the market cost. Rather than revealing a program
run amuck, the high participation of infants in WIC signals a successful
government policy that helps ensure the nutritional status of millions of
Overall, however, it has been estimated that only about 80 percent
of those eligible for WIC (including women and preschool children) are able to
get benefits. More health and social services for the mothers and children most
at risk are urgently needed, but many other programs can provide these services,
along with WIC. Let's be sure that we have utilized all the resources to their
utmost and coordinated programs' efforts, before we propose taking food away
from low-income women and children.
Besharov and Germanis have raised many provocative issues, and I
hope that this stimulates a constructive discussion of ways to improve services
for low-income mothers and children. But I have read the research literature,
and I remain confident that WIC is effective and well run. We can and should
refine the WIC program to improve the health of lowincome mothers and children,
but let's not forget program fundamentals.
A reply by Douglas J. Besharov and Peter Germanis
IN his response to our article, Leighton Ku, a careful researcher
and a self-described advocate of the Women, Infants and Children (WIC) program,
demonstrates what is so sadly wrong about the public-policy debate these days:
Eager to defend or expand a social program, advocates and politicians trumpet
favorable research findings to claim that the program "works." Often, they
assert that the program actually saves public money by preventing other social
problems or expenditures. Never mind that the assertion is questioned by
unbiased experts in the field and that, even if true, the impact is insufficient
to make a real dent in the underlying problem.
As evaluation studies have proliferated in recent years, so have
such advocacy-oriented research claims. Probably the best example concerns Head
Start. Research on the Perry Preschool Program dating back to the 1960s
suggested that early-childhood education programs can substantially affect
children's later lives, in areas such as school drop-out rates, criminal
behavior, out-of-wedlock teen births, welfare dependency, and unemployment.
Advocates claimed that the program saved from $ 3 to $ 7 for each dollar spent.
To deal with the fact that the Perry Preschool Program only vaguely resembled
Head Start, they often loosely attributed this cost-benefit to "Head Start-like"
programs. Since most of us believe that a child's upbringing matters, such
evaluations were widely accepted. But no other rigorously evaluated,
early-childhood program has had even remotely similar results (sharply
undermining even the Perry Preschool results). Even those programs that report
initial, impressive improvements in children's performance conclude that these
gains "fadeout" over time.
Most recently, the federal government mounted the Comprehensive
Child Development Program (CCDP), a five-year, $ 125 million early-intervention
program at 24 sites. Despite an average annual investment of $ 15,768 per family
(above and beyond welfare payments, food stamps, Medicaid, housing, etc.), the
children who received the services had outcomes that were little different from
those who did not.
Family-preservation services are another example of an oversold
social program. Again, the idea makes sense: Use intensive rehabilitative and
supportive services to improve parenting so that children do not have to be
removed from home and placed in foster care. And again, out-sized results from
one or two early studies were used to justify a massive federal program-in this
case, the Family Preservation and Support Program, funded at almost $ 1 billion
for its first five years. The ink had not yet dried on the new law before other,
more carefully designed studies deflated claims that each dollar spent on family
preservation services would save $ 5 to $ 6 in foster care and other
ONE could provide many other examples and, in effect, our article
simply added WIC to the list of programs whose exaggerated impacts should be
brought down to earth. We made several broad points: There is a widespread and
bipartisan belief that WIC is a tremendously cost-effective program. The most
common claim, to quote a 1997 speech by Agriculture Under Secretary Shirley
Watkins, is that "for every dollar spent in WIC benefits, three dollars are
saved in Medicaid dollars." And in 1998, an editorial in the Washington Post
asserted that "repeated studies have shown that the program saves far more in
health care costs than it spends." Such claims are simply untrue. The relevant
research applies to only a small subset of the WIC caseload-pregnant women.
Moreover, most of the research upon which the costs and benefits are calculated
are plagued by unresolved problems of selfselection and simultaneity bias. The
widely proclaimed results are, in other words, at the high end of possible
impacts. Nevertheless, some parts of the WIC program undoubtedly make a
difference in the lives of low-income women and children. Here is exactly what
WIC for pregnant mothers has perhaps zero to substantial impacts
on infant mortality, prematurity, and birth weight. But the rest of the program
(for infants, children, and postpartum and breastfeeding mothers) has small to
modest impacts on anemia and nutrient intake. There is also a glimmer of
evidence that WIC's beneficial effects are concentrated among the most needful
The priority should be to learn more about what in WIC improves
the health of low-income mothers and their young children-and what doesn't.
Thus, and most important, we did not argue that WIC should be defunded, or even
cut back. Instead, we proposed that: (1) more WIC resources should be targeted
on the most needful families; (2) counseling services should be intensified-and
made more directive; (3) states should be allowed to exceed federal limits on
spending for WIC services; and (4) alternative service configurations should be
tested. Moreover, we cautioned that these ideas "are untried and, therefore,
should be carefully evaluated." Hardly a radical set of proposals.
Yet Ku says that our review is "incomplete and stilted." He says
we ignored hundreds of studies, but, as he notes, most are of highly
questionable validity ("not rigorous evaluations," are his words)-and are
ignored in most research syntheses.
Significantly, Ku does not defend the benefit-cost estimates we
criticize, nor does he assert a particular statistical impact for the program.
The plain truth is that no one knows how much difference the program really
makes. As recently as 1994, Ku and other researchers at the Urban Institute
concluded: "More research is needed on the effect of WIC participation for
children (over half of all WIC recipients), given that this is the group that
will grow most under full funding."
SO far, of course, exaggerating WIC's impact has helped fuel the
program's expansion. In the last 10 years, the number of WIC recipients has more
than doubled. Last year, the bill reauthorizing WIC sailed through the House of
Representatives by a vote of 383 to 1. But just as the public and politicians
have, over time, gained more nuanced understandings of Head Start,
family-preservation services, and a host of other once-favored programs, so too
will they eventually acquire a more realistic view of WIC.
In the meantime, the problems that it and other socialwelfare
programs are meant to address remain and fester. Hence, rather than try to
counter Ku's comments, we prefer to underscore the broader sociopolitical
tendencies that they reflect.
Circle the wagons, thereby preventing programmatic improvement.
Ku's real complaint is not that we have misstated the evidence of WIC's effect
but that, if accepted, our view of the research evidence would undercut public
and political support for the program. That is a valid concern. But obscured by
rhetoric that WIC "works" are potentially life-saving questions about how to
improve it and thus the well-being of possibly thousands of underprivileged
children. Sound policy making requires that programs be continually evaluated
and, when necessary, their services reoriented or, at least, refined.
Demonize skeptics, thereby avoiding the need to address their
concerns. Although we appreciate the general tone of Ku's response, at one point
he accuses us of "acting like the fringe groups who wonder whether smoking
tobacco really causes lung cancer." In case there is any question: Yes, we think
smoking causes lung cancer in many people. But some long-time smokers escape
serious harm. Similarly, WIC benefits many, but surely not all, participants. At
another point, Ku says that our proposal would be "taking food away from
low-income women and children." Honest, we don't want anyone to go hungry. We
just want to help those who most need the WIC program.
Blame insufficient funding, thereby excusing inadequate theory and
poor implementation. When forced to acknowledge a program's weaknesses, the
advocate's first riposte is that not enough money is being spent on it. By many
estimates, the cost of full-day, full-year Head Start now exceeds $ 10,000 per
year, compared to the average of about $ 6,000 spent by middle-class families
for equivalent hours of child care. Higher funding may improve services, but
often the services are simply irrelevant to the family's problems or are so
poorly managed that they have little impact. (Remember the $ 15,768 per family
spent by the unsuccessful CCDP.)
Include the middle class, thereby creating an everlarger
constituency for government spending. As we point out, about 50 percent of all
newborns qualify for WIC, as do 25 percent of children aged 1 to 5. Ku
attributes this to "an alarmingly high level of poverty and near poverty." But
income eligibility for WIC, one of the most generous of federal
public-assistance programs, reaches to families of four with incomes up to $
30,000 a year. One wishes these families had higher incomes but to call them
"poor" is simply wrong. (In 1997, the median income for all American families
with children was $ 43,545.)
Don't trust the states and localities, thereby reducing
programmatic responsiveness and stifling innovation. In the 1930s, the federal
government helped states because they needed additional funds; but, in the
aftermath of the civilrights struggles of the 1960s, federal involvement was
increasingly motivated by a corrosive mistrust of the states. The welfare reform
of 1996 was a major step in the other direction, but most federal programs still
mandate the specifics of state implementation in excruciating detail. America,
however, is a diverse, continental nation. What works for New York City may not
work for Albuquerque. More importantly, centralized planning did not work for
the Soviet economy, and it has not worked for American social-welfare services.
At any given time, there are a multitude of promising ways to address child
poverty, inadequate nutrition, and child maltreatment. Limiting the states to a
single, centrally funded approach has foreclosed the marketplace of ideas that
should characterize a federal system.
EACH of these points, of course, challenges conventional social
policy, at least as it has been conducted since the 1960s. Recently, we have
seen crime decline, probably because of improved policing, rather than because
of public-jobs programs. Similarly, out-of-wedlock births have declined,
probably as a result of more conservative attitudes, rather than the free
distribution of contraceptives; and welfare rolls have declined, probably
because of work expectations and the end of the entitlement mentality, rather
than through job training. If social programs are to succeed, they must be open
to reconsideration and reorientation. We hope that raising these points does not
mean we are "acting like a fringe group." Indeed, we hope there is an emerging
majority that favors a more open-minded and candid discussion of America's
pressing social problems.
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