In 2021, 1 in 10 American households experienced food insecurity, an issue exacerbated by the COVID-19 pandemic.[1] Diet-related diseases such as diabetes, heart disease, and cancer are some of the leading causes of death and disability in the U.S. Each year in the U.S. there is an estimated $52.8 billion in excess health care costs as a result of adults experiencing food insecurity.[2] Since recognizing the influence of nonmedical factors such as socioeconomic status, education, and physical education on health, there have been a growing number of initiatives to address social determinants of health (SDOH) within the health care system. Food is medicine interventions are tailored to respond to the connection between food and health in order to help prevent, manage, or reverse diet-related disease.[3] Food is medicine interventions may include medically tailored meals, produce prescriptions, and medically tailored food packages. These interventions have been associated with decreased inpatient hospital admissions, decreased overall healthcare costs, increased medication adherence, and increased diet quality.[4] The concept of using healthy foods to reduce diet-related disease in the U.S. is increasing in popularity. There is bipartisan support for food is medicine initiatives to target food insecure and medically vulnerable populations.
White House Conference on Hunger, Nutrition, and Health Call for Action[5]
In September 2022, the Biden-Harris Administration hosted the first White House Conference on Hunger, Nutrition, and Health in over 50 years. During the conference, the Administration also released the National Strategy on Hunger, Nutrition, and Health (National Strategy) with the goal of ending hunger and increasing healthy eating and physical activity by 2030. The National Strategy laid out a five-pillar plan to achieve this 2030 goal, with one of the most crucial initiatives for the food is medicine movement being to integrate nutrition and health. The National Strategy pillar and food is medicine interventions share two similar motives: to prioritize the role of nutrition and food in the health care system and address the nutritional needs of all people.
The National Strategy outlined the goal to increase access to nutrition services in order to prevent, manage, and treat diet-related diseases through the expansion of Medicare and Medicaid beneficiaries’ access to food is medicine interventions. As discussed later, there are a variety of different methods that can be utilized to increase beneficiaries’ access to food and nutrition services. Another National Strategy priority is to increase screening for food insecurity and connecting those in need with the appropriate services. Incorporating SDOH, like food insecurity screenings, into healthcare protocols allows practitioners to treat the root causes of health issues. The National Strategy recommends states leverage all available federal authorities to expand coverage of food is medicine interventions and collaborate with non-profit or community-based organizations to establish state-funded produce prescription programs in low-income communities. Additionally, health insurance companies are encouraged to provide and expand coverage of nutrition services, including produce prescription programs and/or medically tailored meals for vulnerable populations. It is important to understand how CMS, states, and managed care plans have integrated food and nutrition services in the past when examining the current landscape of the food is medicine movement.
Access to Food and Nutrition Services Through Medicaid
As noted in the National Strategy, there is a need to increase access to food and nutrition services through Medicaid in order to address hunger and diet-related disease. In January 2021, CMS offered new guidance for State Health Officials on addressing SDOH through Medicaid, which laid down the framework for states and plans interested in health-related social needs such as food insecurity.[6] Efforts to support the food is medicine movement have gained popularity throughout the country. In the past, state Medicaid agencies and Medicaid managed care plans have partnered with community-based organizations to provide nutrition education, food insecurity screenings and referrals, tailored food is medicine interventions, and food infrastructure/community investments. There are a number of ways states and plans have provided access to food and nutrition services to Medicaid beneficiaries.
State Plan Coverage. [7] State plans have the authority to cover some nutrition education and referral services by offering optional coverage under Medicaid benefit categories. In the past, medical nutrition therapy, diabetes management programs, and case management/care coordination services have been covered by some state plans.
Medicaid Managed Care. State and individual health plans have addressed food access and nutrition issues among Medicaid participants through Medicaid managed care. States can incentivize or require plans to offer services related to food access or nutrition in their contracts with managed care organizations (MCOs). In the past, states have leveraged federal regulations to contractually require plans to screen enrollees for social needs, such as food insecurity.[8] As of 2021, 24 states required managed care plans to screen enrollees for social needs, 11 required the incorporation of uniform SDOH questions within screening tools, and 28 required that enrollees would be provided referrals to social services.[9]
Public Grants. The U.S. Department of Agriculture (USDA) offers the Gus Schumacher Nutrition Incentive Program (GusNIP). GusNIP offers federal support through three grant programs: Nutrition Incentive Program; Produce Prescription Program; and Training, Technical Assistance, Evaluation, and Information Centers Cooperative Agreements. Most influential to the food is medicine movement are the produce prescription program grant offerings. These grants fund projects that distribute fruit and vegetable prescriptions to reduce individual or household food insecurity with the intention that access to healthy foods will reduce healthcare usage and associated costs.[10]
Pilots. The CMS Innovation Center (CMMI) developed and executed models in the past that, while no longer active, addressed diet-related diseases with accessibility to healthy foods. The Accountable Health Communities Model was established to test whether addressing health-related social needs could reduce health care costs and utilization among community Medicaid and Medicare beneficiaries.[11] The Medicaid Incentives for the Prevention of Chronic Disease Model provided incentives to Medicaid beneficiaries who participated in prevention programs and demonstrated changes in health risk and outcome.[12] In some states, the prevention programs focused on altering behaviors that lead to diabetes and cardiovascular disease by providing participants with nutrition counseling, exercise classes, and medically tailored meals.
Medicaid Waivers. States have the ability to implement innovative Medicaid policies through CMS-approved waivers. Section 1915(c) Home and Community-Based Services Waivers have been used to provide coverage of meal preparation support or home delivered meals to Medicaid beneficiaries that would otherwise need institutional care. Sates may also elect to use the savings from Section 1915(b)(3) Managed Care Waivers to provide additional services for Medicaid beneficiaries that are not covered under the State Plan. According to the previously mentioned CMS guidance on addressing SDOH through Medicaid, these additional benefits may include health-related nutrition needs.[13] States have also utilized Section 1115 Demonstration Waivers to address food access and nutrition services among Medicaid beneficiaries. Arkansas, Massachusetts, North Carolina, and Oregon have used this waiver to provide Medicaid beneficiaries with services such as nutrition counseling and education, home delivered meals, medically-tailored food prescriptions, provision of cooking supplies, fruit and vegetable prescriptions, and food insecurity screening.[14] Delaware, Maine, New Jersey, New Mexico, New York and Washington currently have pending Section 1115 waiver requests for nutrition and food support.[15]
Access to Food and Nutrition Services Through Medicare
While a majority of the efforts to integrate food is medicine interventions into healthcare are focused on Medicaid, Medicare plans have started to adopt food and nutrition benefits for eligible enrollees. Original Medicare (Parts A and B) does not currently offer food is medicine benefits; however, it does cover nutritional therapy services for qualifying beneficiaries.[16] As of 2020, some Medicare Advantage plans (Part C) have begun to cover food services for select subgroups of enrollees. The National Strategy has called on HHS CMS to expand Medicare beneficiaries’ access to food is medicine interventions and nutrition counseling. These service offerings have been available to some Medicare beneficiaries in the past through the following avenues.
Medicare Part B.[17] Beneficiaries with diabetes or kidney disease, those who have undergone a kidney transplant in the last 36 months, and individuals with a doctor’s referral qualify for medical nutrition therapy services through Medicare Part B. These services include an initial nutrition and lifestyle assessment; individual and/or group nutritional therapy services; help managing lifestyle factors that affect diabetes; and follow-up visits for diet management. Currently, only a registered dietitian can provide medical nutrition therapy services to eligible Medicare beneficiaries.
Medicare Advantage (MA) Plans. The Chronic Care Act, enacted as part of the Bipartisan Budget Act of 2018, provided authority for MA plans to offer special supplemental benefits for the chronically ill (SSBCI) beginning in 2020.[18] SSBCIs do not have to be primarily health related, but must have a reasonable expectation of improving or maintaining the health of chronically ill enrollees.[19] Under HHS guidance, plans may determine what benefits to offer beyond those already permitted in MA. Two of the most common supplemental nutrition benefits offered by MA were food/produce and meals beyond a limited basis.[20] SSBCIs were intended to enable MA plans to tailor benefit offerings, address gaps in care, improve the health and function of the chronically ill population.[21] Non-primarily health-related supplemental benefits, such as food/produce and meals beyond a limited basis, were also offered by Value-Based Insurance Design (VBID) plans. The VBID Model, which is scheduled to run through 2024, is designed to test alternative ways to deliver and pay for services in MA.[22] The VBID benefits, while of the same type and scope as the SSBCIs, are offered to subgroups of enrollees based on the enrollees’ chronic condition(s) or their socioeconomic status.[23] The VBID Model allows plans unique flexibilities for targeting supplemental benefits to subgroups of enrollees beyond the previously established chronically ill population. Overall, a majority of MA enrollees (71%) were in a plan that offers meal benefits in 2022; however, there are notable differences in rates across firms.[24]
Looking Ahead
President Biden’s FY 2024 Budget Request, released on March 9, 2023, takes several steps to advance the Administration’s National Strategy. Specifically, it calls upon Congress to expand Medicare coverage for nutrition and obesity counseling and to include a new pilot project on medically-tailored meals.[25] The budget request includes a total of $137 million earmarked for the HHS to address specific commitments made as part of the White House Conference on Hunger, Nutrition, and Health and the corresponding National Strategy. This includes $72 million to expand CDC’s State Physical Activity and Nutrition program, which implements evidence-based strategies to reduce chronic disease, to all 50 states, the District of Columbia, and 14 territories. Within this total, the budget also includes $12 million in nutrition services for older adults and people with disabilities through the Administration for Community Living, and $12 million in FDA’s budget to improve labeling to empower consumers to make good food choices.
The President’s budget request comes as Congress continues its work to reauthorize the Farm Bill — the most comprehensive piece of nutrition and agriculture legislation passed by Congress at regular (typically five-year) intervals and which has a far-reaching impact on farmers, ranchers and households across the U.S. The current authorizing legislation expires on September 30, 2023, the end of the fiscal year. The significant impact of the Farm Bill legislation makes it a ‘must pass’ priority in the 118th Congress. The House and Senate agricultural committees began field hearings late last year on the 2023 Farm Bill, and are now working almost exclusively on drafting legislation that will reauthorize the bill’s 12 titles.
Nutrition programs have so far been at the forefront of Congress’ negotiations to reauthorize the legislation. Despite the name, more than three-quarters of the legation is traditionally allocated to the Supplemental Nutrition Assistance Program (SNAP) and other important nutrition initiatives, like the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). In previous Farm Bills, nutrition assistance programs have received a majority of the funding. In the 2018 reauthorization, 76% of Farm Bill spending was devoted to programs under the Nutrition title (primarily SNAP), with the 2023 projection reaching 85% of the Farm Bill baseline.[26] Consistent with larger trends, GusNIP and its public grant programs saw an increase in annual funding over five years from $45 million to $56 million as a result of the last Farm Bill.[27]
During a Senate Agriculture Subcommittee hearing in December 2022 food is medicine interventions received bipartisan support with members highlighting the concept as a priority for the upcoming Farm Bill.[28] Senator Cory Booker (D-NJ), who previously chaired the Senate Agriculture’s subcommittee on food and nutrition, specialty crops, organics and research supports substantially scaling up food is medicine programs as a top priority in the 2023 Farm Bill. Committee member and physician Roger Marshall (R-KS) said at the December hearing he plans to introduce legislation with Senate Agriculture Committee Chairwoman Debbie Stabenow (D-MI) to implement a larger-scale pilot program to evaluate the cost savings and health benefits of Medicare recipients who are sent home from hospital stays with medically tailored meals. Along these lines, the Medically Tailored Home-Delivered Meals Demonstration Pilot Act of 2021 has also received bipartisan support within Congress. This legislation would direct the Secretary of HHS to conduct a 3-year demonstration pilot program to provide medically tailored meals for some of the nation’s most vulnerable Medicare beneficiaries.[29] This bill would fill a gap in coverage as Medicare Parts A and B do not currently cover medically tailored meals for beneficiaries. With national efforts predominately focused on Medicaid food is medicine programs, this bill would support the nutrition needs of traditional Medicare beneficiaries. While the Food is Medicine movement appears to be gaining momentum among Washington policymakers on both sides of the aisle, and the Farm Bill seems to offer a promising vehicle to expand – or at least pilot – access to medically-tailored food programs, the omni-present backdrop of a divided Congress with significant gaps in policy and spending priorities calls into question whether the final 2023 Farm Bill will give the movement a bigger platform, or if the integration of food and nutrition into healthcare will continue to
[1] Coleman-Jensen, A., Rabbitt, M. P., Gregory, C. A., & Singh, A. (2022, September 7). Household Food Security in the United States in 2021. Retrieved from USDA Economic Research Report No. (ERR-309) 51 pp: https://www. ers.usda.gov/publications/pub-details/?pubid=104655
[2] Berkowitz, Seth, Sanjay Basu, Craig Gundersen, and Hilary K. Seligman. “Peer Reviewed: State-Level and County-Level Estimates of Health Care Costs Associated with Food Insecurity.” Preventing chronic disease 16 (2019).
[3] Garfield, Katie, Julia Koprak, and John Haughton. Issue brief. Addressing Nutrition and Food Access in Medicaid: Opportunities and Considerations. The Food Trust, 2022. https://thefoodtrust.org/wp-content/uploads/2022/07/report_addressing-nutrition-and-food-access-in-medicaid_2021.original.pdf.
[4] Downer, Sarah, Seth A. Berkowitz, Timothy S. Harlan, Dana Lee Olstad, and Dariush Mozaffarian. “Food is medicine: actions to integrate food and nutrition into healthcare.” bmj 369 (2020).
[5] White House, National Strategy on Hunger, Nutrition, and Health (Washington, DC: White House, 2022). https://www.whitehouse.gov/wp-content/uploads/2022/09/White-House-National-Strategy-on-Hunger-Nutrition-and-Health-FINAL.pdf
[6] Department of Health & Human Services, Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH), SHO#21-001 (Baltimore, MD: Department of Health & Human Services, 2021), https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf
[7] Garfield et al., “Addressing Nutrition and Food Access in Medicaid: Opportunities and Considerations”.
[8] Diana Crumley et al., Addressing Social Determinants of health via Medicaid Managed Care Contract and Section 1115 Demonstrations, (Hamilton, NJ: Center for Health Care Strategies, 2018), https://www.chcs.org/media/ Addressing -SDOH-Medicaid-Contracts-1115-Demonstrations-121118.pdf
[9] “States Reporting Social Determinant of Health Related Policies Required in Medicaid Managed Care Contracts,” KFF, October 27, 2021, https://www.kff.org/other/state-indicator/states-reporting-social-determinant-of-health-related-policies-required-in-medicaid-managed-care-contracts/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D.
[10] “Gus Schumacher Nutrition Incentive Program.” National Institute of Food and Agriculture. Accessed March 3, 2023. https://www.nifa.usda.gov/grants/programs/hunger-food-security-programs/gus-schumacher-nutrition-incentive-program.
[11] “Accountable Health Communities Model: CMS Innovation Center.” Innovation Center. Centers for Medicare & Medicaid Services. Accessed March 3, 2023. https://innovation.cms.gov/innovation-models/ahcm.
[12] “Medicaid Incentives for the Prevention of Chronic Diseases Model: CMS Innovation Center.” Innovation Center. Centers for Medicare & Medicaid Services. Accessed March 3, 2023. https://innovation.cms.gov/innovation-models/mipcd.
[13] Department of Health & Human Services, Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH).
[14] “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State.” Kaiser Family Foundation, February 2, 2023. https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/#Table3.
[15] Kaiser Family Foundation, “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State.”
[16] “Nutrition Therapy Services.” Medicare.gov. Accessed March 29, 2023. https://www.medicare.gov/coverage /nutrition-therapy-services.
[17] Jeannie Fuglesten Biniek et al., “Extra Benefits Offered by Medicare Advantage Firms Vary,” KFF, November 16, 2022, https://www.kff.org/medicare/issue-brief/extra-benefits-offered-by-medicare-advantage-firms-varies/.
[18] Congress.gov. “H.R.3436 – 116th Congress (2019-2020): Chronic Care Management Improvement Act.” December 15, 2020. https://www.congress.gov/bill/116th-congress/house-bill/3436.
[19] Kathryn Coleman, “Implementing Supplemental Benefits for Chronically Ill Enrollees” (official memorandum, Baltimore, MD: Department of Health & Human Services, 2019), https://www.cms.gov/Medicare/Health-Plans/ HealthPlansGenInfo/Downloads/Supplemental_Benefits_Chronically_Ill_HPMS_042419.pdf
[20] Michelle B. Rosenberg, Medicare Advantage: Plans Generally Offered Some Supplemental Benefits, but CMS Has Limited Data on Utilization, GAO-23-105527. Washington, DC: Government Accountability Office, 2023.
[21] Coleman, “Implementing Supplemental Benefits for Chronically Ill Enrollees”.
[22] Rosenberg, Medicare Advantage.
[23] Rosenberg, Medicare Advantage.
[24] Fuglesten Biniek et al., “Extra Benefits Offered by Medicare Advantage Firms Vary.”
[25] U.S. Department of HHS, FY 2024 Budget in Brief, accessed at https://www.hhs.gov/sites/default/files/fy-2024-budget-in-brief.pdf.
[26] Renée Johnson and Jim Monke, Farm Bill Primer: What Is the Farm Bill? CRS Report No. IF12047 (Washington, DC: Congressional Research Service, 2023), https://crsreports.congress.gov/product/pdf/IF/IF12047
[27] Fatka, Jacqui. “Booker Highlights Food as Medicine Programs as Farm Bill Priority.” AgriPulse Communications Inc RSS. Agri-Pulse Communications, Inc., February 14, 2023. https://www.agri-pulse.com/articles/18618-booker-said-food-as-medicine-farm-bill-priority.
[28] Food as Medicine: Current Efforts and Potential Opportunities: Hearing before the Subcommittee on Food and Nutrition, Specialty Crops, Organics, and Research, 117th Cong. (2022), https://www.agriculture.senate.gov/ hearings/food-as-medicine-current-efforts-and-potential-opportunities
[29] “McGovern, Walorski, Pingree, Evans Introduce Legislation to Address Gaps in Medicare Coverage That Lead to Poor Health Outcomes.” U.S. Representative Jim McGovern, September 24, 2021. https://mcgovern.house.gov/news/documentsingle.aspx?DocumentID=398746.