In 2016, West Virginia conducted a small pilot in nine counties that was similar to the new federal rule change, which will require 20 hours of employment per week to receive SNAP benefits. Not only did the pilot fail to spark an increase in employment, food pantries had difficulty compensating for increased demand, there were negative economic outcomes and, obviously, people's access to food was diminished.

The impact of SNAP dollars goes far beyond food itself. It is estimated that there is an economic multiplier effect that yields $1.79 for every $1 of SNAP benefits.

I sat in a West Virginia Senate Health Committee meeting in 2017 when outcomes from the nine pilot counties were discussed. The pilot had been specifically designed to test counties with the lowest unemployment rates across the state. However, people not only struggled to find employment, they struggled to find even volunteer opportunities that were allowed in lieu of paid employment when there were no jobs to be had.

Although the work requirement pilot failed miserably, Gov. Jim Justice signed legislation that pushed the program statewide in 2018. It doesn't surprise me that our state's only billionaire and luxury resort owner wouldn't understand hunger. (And I guess it shouldn't surprise me that he doesn't understand the economic impact this legislation will have because he seems to have a hard time paying his own bills.)

There is a provision for waivers for counties with peak unemployment rates and limited opportunities, but even those waivers will be phased out by 2022. Forty-six of West Virginia's 55 counties qualify for exemption due to a lack of jobs.

I see patients making choices that have negative impacts on their health, which will only worsen when their SNAP benefits are gone. And I'm not the only one. The AAFP urged the USDA to use caution when the agency issued the proposed rule that would limit SNAP benefits, noting that food insecurity is a predictor for higher health care utilization and negative psychological and health outcomes.

My state is not alone in having food access challenges, and it's not alone in having outrageous poverty rates. But it is a great place for studying social service programs and the impact that things like the work requirement for SNAP can have because we have a population that already is on the edge of survival without more hurdles being added. High poverty, including among employed people, means increased reliance on support services for food. Often our counties with the highest poverty rates are the same counties with poor infrastructure that lack public transportation and clean drinking water. The county I work in doesn't even have a grocery store. Recent data shows West Virginia has the lowest median household income in the country.

My primary identity in the community is as a physician, but I have spent quite a bit of time working on the food access issues here. When our county's only grocery store closed in 2015, I was shocked. It eventually reopened, but when it failed again this year I was ready. I rallied a group of organizations and individuals who I thought could save the store. We met via conference call a couple months before the actual closure, but we weren't able to keep the store open. And we haven't been able to open another store. So now we are thinking outside the box.

We have increased food distribution events because the small food pantries in the area don't have the necessary infrastructure or storage for things like produce and protein. We have huge distribution events where the Mountaineer Food Bank and the United Way of West Virginia come together, and we are averaging more than 1,000 people -- roughly 10% of the county -- receiving food at these events during a two- to three-hour window. Cars, and lots of trucks, line up blocking roads in town waiting to pull through the line, and volunteers load food into vehicles based on the number of people who live in each house. It is not uncommon for someone in a truck to pick up food for multiple families. It is just as common for a car driver to pick up for a neighbor or family member and get nothing for themselves. Obviously, this is not a sustainable way to feed people, but it is a way to fill the gap while we work on solutions.

We have had meetings and discussions about options, resources, economic viability and need, but to be honest, there isn't much agreement or momentum toward a brick-and-mortar store. So those of us who are tired of waiting on a plan everyone can get behind are moving forward with a less traditional plan of a mobile grocery store. The United Way is leading the charge with an encouraging amount of support. No, it won't be like going to Walmart or Kroger, but it will be adaptable to the needs and requests of an area. It can get closer to people who may be able to get to the end of the holler but can't get all the way to town. Sure, there are hurdles to overcome, and no, it isn't ideal, but I'm tired of trying to do things the traditional way and failing.

Most of my patients face a 40- to 50-mile drive one way to reach a grocery store. If it costs $10 in gas to get to a store and back, that is $10 they can't spend on food, which is a significant amount of money for those who might only have $50 to start with. When the trip itself is a financial burden, you don't go to the store often. People buy processed, shelf-stable foods, the exact things we advise them to avoid. And sometimes they choose a trip to the store rather than a visit to my office, a subspecialist or the pharmacy.

I can't help but be reminded of a quote that's attributed to Winston Churchill: "Americans will always do the right thing -- after they have tried everything else." So, I'm glad my son realized that the new administrative rule isn't the right thing. I wish our wealthy elected leadership could see it, too. You can't demand work for food in a community where there is not enough work, and you have to be open to new ideas regarding work and food.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.

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