Food insecurity is common among individuals with kidney failure undergoing hemodialysis and may contribute to worse clinical outcomes. Using data from 200 participants in the PEER-HD study from Bronx, NY, and Nashville, TN, this secondary analysis examined whether food insecurity—defined as concern about affording food—was associated with hospitalization or emergency department (ED) visits over an 18-month follow-up period. Food-insecure individuals showed higher median rates of acute care utilization and lower median albumin levels, although the overall association between food insecurity and hospitalization/ED visit rate was not statistically significant after adjustment. Stratified analyses indicated significant associations among adults older than 55 years and among men, suggesting differential vulnerability across demographic subgroups. Food-insecure participants reported greater depressive symptoms, lower perceived social support, lower self-efficacy, and worse emotional and physical functioning. Adjusting for these psychosocial and socioeconomic factors substantially attenuated the association between food insecurity and healthcare use. Findings highlight the complex interplay between social determinants of health, psychosocial burden, and clinical outcomes in dialysis populations.