PROJECT SUMMARY/ABSTRACT Food insecurity—the economic and social condition of inconsistent access to healthy food—is associated with worse cardiovascular health. Whether food assistance related social policies can improve cardiovascular health among low-income adults in the US is unknown. The Supplemental Nutrition Assistance Program (SNAP) is the largest US government-funded program providing food assistance. In 2021, at the cost of approximately $114 billion, 41.5 million Americans received SNAP benefits. As SNAP is administered by individual states, there are variations in policies related to eligibility assessment and ease of application that significantly impact participation levels. Although SNAP participation has been associated with improved food security, poverty reduction, and lower healthcare expenditures, it's impact on cardiovascular health is unknown. The mechanisms by which SNAP, and poverty reduction programs in general, influence cardiovascular health is unknown, but may be mediated through mechanisms such as medication adherence and psychosocial stress. In a previously published analysis, we found that implementation of state level policies associated with higher SNAP participation was associated with slower growth in diabetes prevalence. However, whether SNAP participation, or the policies impacting this participation, impacts cardiovascular health at an individual level is unknown. During the COVID-19 pandemic, the amount of SNAP benefits received by participants increased, but some of these increases are scheduled to expire. How SNAP benefit amounts impact cardiovascular health related measures is therefore important to understand. Aim 1 of the proposed research will use data from a nationally representative survey of older adults – the Health and Retirement Study (HRS) – linked with Medicare or Medicaid administrative claims data to identify whether SNAP participation among low-income individuals with cardiovascular disease is linked with improvements in medication adherence and psychosocial stress as well as lower healthcare utilization. Aim 2, using Medicare and all-payer claims data, will examine whether changes in state-level SNAP policies associated with SNAP participation lead to changes in the incidence of acute cardiovascular events among low-income adults. We will also study whether specific policy categories are associated with a greater change in health outcomes. In Aim 3 we will examine how changes in SNAP benefit amounts influence cardiovascular health-related measures. We will examine the temporary increase in SNAP benefit amounts that occurred nationwide from 2009 to 2013 as a result of the Recovery Act of 2009 and evaluate whether these changes resulted in differences in medication adherence, healthcare utilization, and health outcomes among SNAP participants with cardiovascular disease. The proposed research aims will require robust causal inference techniques to disentangle the effect of SNAP from other pot...