CMS change could slow the crucial growth of ‘food as medicine’

Sometimes, an apple a day really is just what the doctor ordered.

And for the past several years, organizations like About Fresh, the Boston-based nonprofit where I work, have been developing tools to make such produce prescriptions possible for those who can’t afford the fresh fruits and vegetables they need. Since January 2021, we have enrolled more than 4,101 Medicaid members in our Fresh Connect produce prescription program, and to date they have spent nearly $2.8 million on the fresh fruit and vegetables they need to be healthy.

In the last six months of 2022, 74% of Medicaid-funded cardholders in Massachusetts used their Fresh Connect card at least once each month. Those cardholders spent, on average, 83% of their available benefit. Cardholders enrolled in the program for at least 12 months used the program more in month 12 than they did in month six. Those enrolled for at least 24 months were even more active in month 24 than they were in month 12.

About Fresh and Fresh Connect are part of the “food as medicine” movement, which Food Is Medicine Massachusetts defines as “a spectrum of services and health interventions that recognize and respond to the critical link between nutrition and chronic diseases. Food is Medicine interventions consist of healthy foods that are tailored to meet the specific needs of individuals living with or at risk for serious health conditions affected by diet.”

One such intervention is produce prescriptions, which health care providers are increasingly offering to low-income patients so they can better afford the fruits and vegetables they need to consume. Other “food as medicine” strategies include medically tailored meals, nutritional counseling, and cooking classes. All of these are promising tools for treating diet-related diseases, reducing health care costs, and increasing health equity.

But recent guidelines issued by the Centers for Medicare and Medicaid Services are undermining the success of Fresh Connect and programs like it. Despite introducing novel and promising financing mechanisms for food-as-medicine, they ultimately limit the sector’s ability to deploy food-as-medicine interventions, refine their delivery, and better understand their impact.

Moving forward, states using innovative Medicaid financing will not be able to enroll members in food-as-medicine programs for more than six months, regardless of diagnosis or financial circumstance.

Currently, 6 in 10 Americans have at least one chronic disease, many exacerbated by unhealthy diets. These diet-related chronic diseases account for almost 20% of all U.S. health care costs annually.

When people managing chronic, diet-related illness also struggle with chronic poverty, research indicates that health care has to look beyond traditional tools to improve their outcomes. According to landmark studies, clinical care contributes only 20% to health outcomes, while social and economic factors, like income and income-related access to healthy food, contribute 40%. It’s imperative that the health care sector learns how to address health-related social needs at scale to achieve its key objectives.

In practice, this means that the health care sector must adopt food-is-medicine workflows analogous to those it already uses to screen for and treat other chronic conditions. Just as we are all routinely screened for high blood pressure at every checkup, the health care sector should effectively and consistently screen people for food insecurity and then prescribe the appropriate intervention for the appropriate duration, based on the severity of the finding, other underlying risks, and the patients’ own goals.

CMS, which collaborates with states to insure more than 90 million low-income Americans, has been piloting efforts to better understand and address health-related social needs for several years. Reflecting what it has learned, CMS recently updated guidance for states using in-lieu-of-services funding mechanisms to deploy food-as-medicine interventions. CMS has also approved so-called Medicaid 1115 waivers for Massachusetts, Oregon, and New Jersey, which include mechanisms to prescribe specific foods for eligible patients. Similar waivers are pending from Delaware, Maine, New Mexico, New York, and Washington.

However, while CMS’s new in-lieu-of-services (ILOS) guidance and 1115 waivers take steps in the right direction, I believe that their net effect will undermine the agency’s goal to reduce and prevent diet-related chronic disease by 2030, a goal in the National Strategy on Hunger, Nutrition, and Health, released by the Biden-Harris administration in September 2022, as part of the White House Conference on Hunger, Nutrition, and Health.

As CMS expanded innovative funding mechanisms, it also limited patient enrollment in food-as-medicine and other health-related social needs programs to six months per program per year. CMS included this limitation in their recent ILOS guidance and indicated in December that it applies to 1115 waivers as well. This decision constrains the health care sector’s ability to treat diet-related illness, severely limits what the sector can learn about food-as-medicine interventions, and undercuts their potential value.

Research shows that affordability is the leading barrier to healthy eating among low-income Americans. Without targeted assistance to purchase healthy foods, Medicaid members struggling to afford the nutritious food they need, buy the less nutritious food they can afford. Studies indicate that, faced with the impossible tradeoffs that characterize poverty, people will maximize satiating calories rather than nutritional value. It’s doubtful that Medicaid members will continue purchasing a comparable amount of fresh produce once their Fresh Connect enrollment ends.

The Aspen Institute’s Food is Medicine Action Plan notes, “Medically tailored groceries and produce prescriptions have … been associated with improvements in blood pressure, HbA1c, and diabetes self-management.” The report highlights the need for further study to better understand how to implement food-as-medicine to maximize its health care value. The new six-month cap on enrollment from CMS will constrain researchers’ ability to conduct studies focused on the health care value of longer-term enrollments.

As states begin to incorporate health-related social needs programs into their ILOS plans and as more have their 1115 waivers approved to offer food-related interventions, we urge CMS to take the following steps:

• Give state Medicaid agencies the discretion to extend food-as-medicine enrollments beyond six months for eligible members
• Convene a stakeholder task force of leading healthcare providers and payers, food-as-medicine program leaders, and Medicaid members to inform best practices
• Review the evidence as studies are published on food-as-medicine initiatives, to ensure future guidance and waivers are reflective of the latest science and best practices

Health care providers and payers, and organizations like mine, all want food-as-medicine programs to succeed because Medicaid beneficiaries, like all of us, deserve access to care that improves their health, happiness, and hope. CMS can support such care by increasing — not decreasing — access to the nutritious food people need.

Adam Shyevitch is the chief program officer at About Fresh.