Cuando preparaba la comida en su casa de Garden Grove, en California, González también omitía los aguacates, otro alimento básico de la cocina mexicana que también suele ser caro.

“Veía los precios y decía: ‘ok, no importa'”, contó González, quien tiene 47 años, trabaja en un jardín de infantes y recibe alrededor de $500 por mes en cupones de alimentos (food stamps).

Pero esos productos ya no están fuera del alcance de su familia. Desde que se inscribió el año pasado en un programa que premia a los beneficiarios de cupones que compran más productos frescos, González ha llenado regularmente su carrito del mercado con las frutas y verduras de su infancia, no solo aguacates y alcachofas, sino también granadinas, varios tipos de calabaza y otros.

La participación en el programa, llamado “Más Fresco” (More Fresh en inglés), le da a González $40 adicionales por mes para gastar en productos sanos, permitiéndole ampliar el paladar de sus tres hijos nacidos en los Estados Unidos. “Lo bueno es que a mi familia le gusta probar verduras nuevas”, dijo. “Y ahora puedo comprarlas porque tengo dinero extra”.

La Universidad de California-San Diego está administrando el programa “Más Fresco” y estudia sus resultados con una subvención de $3.4 millones del Departamento de Agricultura, que ha financiado , incluidos Illinois, Georgia, Pennsylvania, Minnesota y Nuevo México. El objetivo de los dólares invertidos en esos estados es estimular a los beneficiarios de cupones de alimentos a comprar más productos agrícolas en los mercados de granjeros o en los mercados móviles que visitan los barrios de bajos ingresos.

“Más Fresco” está disponible para los residentes del sur de California en los condados de Los Ángeles, Orange y San Diego que están inscritos en el Programa de Asistencia de Nutrición Suplementaria (SNAP), el nombre oficial de los cupones para alimentos.

El objetivo del programa de cuatro años, al igual que el de sus contrapartes en otros estados, es mejorar las dietas y la salud en general haciendo que los productos frescos sean más asequibles.

“Conocemos la inseguridad alimentaria y, desafortunadamente, las enfermedades crónicas van de la mano”, dijo Joe Prickitt, nutricionista de UC-San Diego, quien es director senior de “Más Fresco”. “Para los participantes de SNAP, existe una barrera de costo real para comprar frutas y verduras: dicen que son demasiado caros”.

Desde que se lanzó “Más Fresco” en febrero de 2017, se ha matriculado a 1,153 participantes, que reciben un promedio de $329 por mes en cupones de alimentos y generalmente viven en hogares de cinco o seis personas. El 90% de ellos son latinos, pero pueden participar adultos de cualquier origen étnico siempre que estén dispuestos a comprar en una de las tiendas de Northgate González Market, una cadena de supermercados latina con sede en Anaheim, California, que es el socio minorista de “Más Fresco”.

Por cada valor en dólares de cupones de alimentos que los inscritos gastan en productos frescos en un mes determinado, reciben recompensas de hasta $10, $20 o $40, que pueden gastar solo en más frutas y verduras. Los investigadores de UC-San Diego que están estudiando el programa variaron los montos máximos de recompensa y los asignaron al azar a los participantes para ayudar a determinar el nivel óptimo en dólares para cambiar los hábitos alimenticios de las personas.

Las seis tiendas participantes de Northgate, dos en cada uno de los tres condados en los que se lleva a cabo el programa, usan tarjetas de fidelidad para registrar las compras de productos y distribuir los créditos. La cantidad de crédito que los participantes han ganado y canjeado se detalla en la parte inferior de sus recibos, y el crédito se transfiere de mes a mes.

La investigación ha demostrado que la asequibilidad es un obstáculo para una alimentación más saludable para personas de recursos modestos. Un realizado por investigadores de las universidades de Harvard y Brown estimó que una dieta saludable cuesta alrededor de $550 más por año por persona que una dieta no saludable.

“Para muchas familias de bajos ingresos, este costo adicional representa una verdadera barrera para una alimentación más sana”, concluyeron los autores. “Sin embargo, esta diferencia de precios diaria es trivial en comparación con las cargas financieras personales y sociales de por vida de las enfermedades crónicas relacionadas con la dieta”.

Un informe de 2016 del Departamento de Agricultura reveló que los beneficiarios de cupones de alimentos gastan un porcentaje menor de sus presupuestos para comidas en frutas y verduras que otros estadounidenses.

Los incentivos financieros como los que se están probando en California pueden ayudar a reducir esa brecha.

Un de un programa de incentivos en Massachusetts descubrió que las personas que recibían cupones de alimentos con 30 centavos extra por cada dólar que gastaban en frutas y verduras consumían casi un cuarto de taza, o 26%, más productos frescos por día que quienes no recibían estos incentivos.

A principios de enero, “Más Fresco” comenzó a inscribir una segunda ronda de hasta 2,000 personas que recibirán el incentivo por un año. Los participantes actuales continuarán en el programa hasta junio.

Prickitt dijo que espera que incluso después de que finalicen sus incentivos financieros, los participantes retendrán lo que han aprendido sobre la alimentación saludable y continúen comprando productos sanos.

Los expertos en política alimentaria señalan que muchos otros factores pueden influir en la elección de alimentos de una familia, incluida la falta de tiempo.

“Si los padres tienen más de un trabajo o los niños están en más de una escuela o actividad, ¿cómo se enseñan las habilidades de cómo se puede preparar la comida, incluso en una semana ocupada?”, dijo Dean Sidelinger, pediatra y médico de salud infantil para el condado de San Diego.

Algunos defensores de las dietas saludables han argumentado que el gobierno no solo debe alentar a las personas a comprar alimentos más saludables, sino también desalentar los hábitos no saludables.

Un de Health Affairs realizado por investigadores de la Universidad de Stanford demostró que prohibir la compra de gaseosas con cupones de alimentos reduciría las tasas de obesidad y diabetes, mientras que un crédito de 30 centavos por dólar para comprar productos frescos por sí solo no lo haría.

En 2017, más de una docena de investigadores de diferentes universidades pidieron a SNAP que eliminara las disparidades de salud relacionadas con la dieta entre los programas para personas de bajos ingresos. Señalaron, por ejemplo, que el programa federal de asistencia alimentaria conocido como Mujeres, bebés y niños (WIC) excluía los refrescos y dulces, pero que las personas aún podían comprar esos productos con cupones de alimentos.

“Hay generaciones de personas enfermas que tienen sobrepeso con diabetes e hipertensión”, dijo Jim Floros, presidente y director ejecutivo de San Diego Food Bank, que ha promocionado el programa “Más Fresco” entre sus clientes. “Eso está completamente relacionado con una dieta pobre, que está vinculada a la pobreza”.

Rebeca González, quien se mudó a los Estados Unidos a los 18 años, decidió revisar los hábitos alimenticios de su familia después que, a su esposo, Javier Landeros, le diagnosticaron diabetes hace dos años. En lugar de comprar galletas, ahora mantiene las frutas y verduras picadas en el refrigerador para los refrigerios.

González dijo que quiere inculcarles a sus hijos los mismos hábitos saludables que su abuela le transmitió.

“Sé que ella nos dio buena comida”, dijo González, “porque vivió 105 años”.

Esta historia fue producida porÌýKaiser Health News, que publicaÌý, un servicio de laÌý.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

When she prepared meals at her family’s home in Garden Grove, Calif., Gonzalez would also omit avocados, a staple of Mexican cuisine that is often costly here.

“I saw the prices and I said, ‘No, never mind,’” said Gonzalez, a 47-year-old child care worker who receives about $500 a month in food stamps.

But those items are no longer out of reach for her family. Since enrolling last year in a program that rewards food stamp beneficiaries for buying more fresh produce, Gonzalez has regularly filled her shopping cart with the fruits and vegetables of her childhood — not only avocados and artichokes, but pomegranates, various types of squash and more.

Participation in the program, called “Más Fresco,” or “More Fresh” in English, gives Gonzalez an additional $40 a month to spend on produce, allowing her to broaden the palates of her three U.S.-born children. “The good thing is my family likes to try the new vegetables,” she said. “Now I can buy them because I have the extra money.”

The University of California-San Diego is administering Más Fresco and studying its results with a $3.4 million grant from the U.S. Department of Agriculture, which has funded in other states, including Illinois, Georgia, Pennsylvania, Minnesota and New Mexico. The dollars invested in those states have been aimed at inducing food stamp recipients to buy more produce at farmers markets or at mobile markets that visit low-income neighborhoods.

Más Fresco is open to Southern Californians in Los Angeles, Orange and San Diego counties who are enrolled in the Supplemental Nutrition Assistance Program, or SNAP — the official name for food stamp benefits.

The goal of the four-year program, like that of its counterparts in other states, is to improve diets and overall health by making fresh produce more affordable.

“We know food insecurity and, unfortunately, chronic disease go hand in hand,” said Joe Prickitt, a UC-San Diego dietitian who is senior director of Más Fresco. “For SNAP participants, there’s a real cost barrier to buying fruits and vegetables. They say they’re just too expensive.”

Since Más Fresco began in February 2017, it has enrolled 1,153 participants, who receive an average of $329 a month in food stamps and typically live in households of five or six people. Ninety percent of them are Latinos, but adults from any ethnic background can join provided they are willing to shop at a participating Northgate González Market – an Anaheim, Calif.-based Latino grocery chain that is Más Fresco’s retail partner.

For every dollar worth of food stamps enrollees spend on fresh produce in a given month, they receive a one-to-one match, up to $10, $20 or $40, which they can spend only on more fruits and vegetables. The UC-San Diego researchers who are studying the program varied the maximum reward amounts and assigned them randomly to participants to help determine the optimal dollar level for changing people’s dietary habits.

The six participating Northgate stores — two in each of the three participating counties — use loyalty cards to tally produce purchases and distribute the credits. The amount of credit participants have earned and redeemed is itemized at the bottom of their receipts, and the credit carries over from month to month.

Research has shown that affordability is an obstacle to healthier eating for people of modest means. A by researchers at Harvard and Brown universities estimated that a healthful diet costs about $550 a year more per person than an unhealthy one. “For many low-income families, this additional cost represents a genuine barrier to healthier eating,” the authors concluded. “Yet, this daily price difference is trivial in comparison with the lifetime personal and societal financial burdens of diet-related chronic diseases.”

A 2016 by the U.S. Department of Agriculture revealed that food stamp recipients spend a smaller percentage of their grocery budgets on fruits and vegetables than other Americans do.

Financial incentives like the ones being tested in California can help narrow that gap.

A 2011 of an incentive program in Massachusetts found that people on food stamps who got an extra 30 cents for every dollar they spent on fruits and vegetables consumed nearly a quarter-cup, or 26 percent, more fresh produce per day than recipients who did not get such an incentive.

Last week, Más Fresco began to enroll a second round of up to 2,000 people who will receive the incentive for one year. The current participants will continue in the program through June.

Prickitt said he hopes that even after their financial incentives end, participants will retain what they have learned about healthy eating and continue buying produce.

Food policy experts note that many other factors can influence a family’s food choices, including lack of time.

“If parents are working more than one job or children are in more than one school or activity, how do you teach the skills of how you can prepare food, even on a busy weeknight?” said Dean Sidelinger, a pediatrician and child health medical officer for San Diego County.

Some advocates for healthful diets have argued that government should not only encourage people to buy healthier food but also discourage unhealthful habits.

A 2014 Health Affairs by Stanford University researchers showed that banning the purchase of soda with food stamps would reduce rates of obesity and diabetes, while a credit of 30 cents on the dollar for buying fresh produce alone would not.

In 2017, more than a dozen researchers from different universities urged SNAP to eliminate diet-related health disparities among programs for low-income people. They noted, for example, that the federal food-assistance program known as Women, Infants and Children, or WIC, excluded soda and candy but that people could still buy those products with food stamps.

“There are generations of unhealthy people who are overweight with diabetes and hypertension,” said Jim Floros, president and CEO of the San Diego Food Bank, which has advertised the Más Fresco program to its clients. “That’s completely linked back to a poor diet, which is linked back to poverty.”

Rebeca Gonzalez, who moved to the U.S. at age 18, decided to overhaul her family’s eating habits after her husband, Javier Landeros, was diagnosed with diabetes two years ago. Instead of buying cookies, she now keeps chopped fruits and veggies in the fridge for snacks.

She said she wants to instill the same healthy habits her grandmother passed on to her.

“I know she gave us good food,” Gonzalez said, “because she lived 105 years.”

This story was produced byÌý, which publishesÌý, an editorially independent service of theÌý.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The cost of insuring her 16-year-old daughter will spike 60 percent in 2018, and it will jump 38 percent for her 13-year-old son.

The price surge stems from a change in federal regulations that allows insurers to recalculate the health risks of children within a family’s premium bill.

“This hurts us, but it will be a total non-starter for a lot of families,” Kennedy-Simington said.

Despite the policy change for kids, they will still be considerably cheaper to cover than their parents. In Kennedy-Simington’s case, her two teens account for more than half of the premium increase but less than one-third of the total 2018 premium.

Premiums are rising for a lot of reasons next year. Among the most publicized is a decision by the Trump administration to stop paying insurers for certain subsidies they provide to low-income health plan enrollees under the Affordable Care Act.

It also allows insurers to charge higher rates for teens than for younger children beginning at age 15, because teenagers typically rack up bigger medical bills. Up until now, the ACA has not allowed any difference in the amount charged for children from birth to 20.

“A 15-year-old running around on his bike has more chance of something happening to him than a 7-year-old playing video games,” said Ron Goldstein, CEO of Choice Administrators, an Orange, Calif.-based health insurance exchange for small businesses. “You get into high school, there’s football and contact sports.”

Open enrollment for 2018 coverage in the individual market, on and off the health insurance exchanges, started Wednesday.

The new age-related rule applies in most states. However, — Alabama, Massachusetts, Minnesota, Mississippi, New Jersey, Oregon and Utah — plus Washington D.C., do not follow the federal rate-setting formula because they have their own.

The U.S. Department of Health and Human Services (HHS) said it revised the way premiums for people under age 21 are calculated to . The change will also “provide a more gradual transition” to pricier adult rates, the agency said.

Under the previous ACA age calculations, turning 21 ushered in an adult rate with a steep 57.5 percent increase. Adult rates then typically increased incrementally each year to reflect the higher medical costs associated with aging, though they are eventually capped at three times the rate of a 21-year old to promote affordability for seniors.

The formula for calculating annual increases for adults older than 21 will not change.

Under the new rule, health plans can charge a one-time 20.5 percent increase next year for children 0 to 14. For kids ages 15-20, rates will increase every year, starting with a sharp hike in 2018 followed by much smaller ones after that.

For 2018, the increases range from 31.2 percent for 15-year-olds to 52.8 percent for 20-year-olds. Those hikes are already baked in to the premiums insurers have set for their 2018 offerings. And they are related only to age — there may be additional increases to cover the overall rise in medical costs.

Although the rate hikes are bigger for 15- to 20-year-olds, medical expenses for infants are , according to the nonpartisan Health Care Cost Institute in Washington, D.C. They drop after age 3, then rise again during the preteen and teenage years, according to the institute.

HHS said a single rate category for children ages 0 to 14 makes sense because it “spreads the cost of newborns, avoiding significant premium increases for families with young children.”

As a result of the sharp one-time increase in 2018, a customer turning 21 the following year would face an age-related bump of that would have applied under the old rule, according to the HHS’ revised rate formula.

Some insurance agents predict the bump in charges for kids will only add to a about higher premiums, particularly given to cut off federal payments for a key consumer subsidy, his administration’s decision to shorten exchange open-enrollment periods in most states to 45 days, and Congress’ failed attempts to repeal Obamacare.

“Of all years to do this … all these increases are just going to be horrifying,” said Helena Ruffin, an insurance agent in Los Angeles.

In addition to a average statewide premium increase, Covered California, the state’s Obamacare exchange, tacked a 12.4 percent surcharge onto “silver-tier” plans — the second-least-expensive level of coverage — to offset Trump’s decision to end federal payments for so-called cost-sharing reduction subsidies, which lower out-of-pocket costs for some low-income consumers.

In many states, premium hikes will be much higher next year.

Covered California spokesman James Scullary said next year’s rate increases will be offset by a corresponding rise in premium tax credits, so the vast majority of consumers who qualify for those tax credits will be protected from the surcharge.

Scullary said Covered California did not have a figure to show how much the rate increase for kids contributed to the average statewide premium hike, but he said the overall impact was “very small.”

But for many families — especially those with more than one child and no tax credits to absorb their rising premiums — the impact isn’t small.

People like Kennedy-Simington, who buy their insurance in the individual market outside of Covered California, don’t have subsidized premiums.

Neither do employees of small businesses, who are also subject to the new rates for children. One , which covers three adults and two teenagers, shows that the kids — ages 15 and 18 — account for 60 percent of next year’s total $412 premium increase.

Some health plans are sending detailed notices to enrollees affected by the rating change.

Kaiser Permanente’s , for example, described 2018 as a “transition year” in which all members under 21 will experience “significant increases.” (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

But there may be one small silver lining: Adults may benefit, at least modestly, from spreading the rising cost of medical care across a wider age band.

The American Academy of Actuaries said in a that raising rates for children to better reflect their costs will reduce adult rates, though by a “significantly smaller magnitude.” The reductions will vary by insurer and depend on the number of children enrolled relative to the number of adults.

Kaiser Permanente said its rate hikes for children would result in “slightly lower increases to older members.”

Kennedy-Simington, a past president of the Los Angeles Association of Health Underwriters, said families with children should compare all possible insurance options, and check to see if they qualify for premium tax credits through Covered California.

“The only way to get prices down is to move from one carrier to another or to downgrade,” she said. “So shopping will be critical.”

This story was produced by , which publishes , an editorially independent service of the .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).