Nov. 21, 2023 – If you’re like 90% of U.S. adults, you don’t meet the government’s dietary recommendations for eating enough fruits and vegetables. Low-income people have an especially big challenge in this respect, as they may lack access to healthy food.
This is important, because diet plays an outsize role in health and health costs. About 60% of American adults have at least one chronic disease, and diet-related diseases such as hypertension, diabetes, and lipid disorders are the most common. In fact, diet is now the leading risk factor for death in the U.S. Poor diet is involved in about 500,000 deaths each year.
Until recently, efforts to improve the nutrition of chronically ill people were mostly the field of public health. Health care providers and insurers did very little about this problem. But now, this may be changing.
The “food as medicine” movement says doctors should use food “prescriptions” as medical treatment. There’s now real money behind this approach, and larger investments are expected as emerging research shows that food as medicine can save money.
The biggest sign of this change is a new report showing that in 2024, 1,475 Medicare Advantage plans – about a quarter of the market – will offer eligible enrollees financial help to buy healthy food, mostly fruits and vegetables. In contrast, when the Centers for Medicare and Medicaid Services (CMS) introduced new rules on the supplemental benefits that Medicare Advantage insurers could offer in 2020, only 101 plans offered this benefit.
Meanwhile, the Biden administration has provided waivers to nine states so they can use Medicaid funds to buy food for chronically sick enrollees. And a growing number of health care systems have joined the food as medicine trend. Among them are systems that own health plans, such as Kaiser Permanente and Geisinger, as well as other big systems like Dignity, Northwell, and Mount Sinai.
Medicare Advantage Plans Take the Lead
The Medicare Advantage plans offer the most solid evidence that the U.S. health care industry is starting to take food as medicine seriously. Most Medicare Advantage insurers lure new members with supplemental benefits such as hearing, vision, and dental services. Since 2019, they have also been allowed to offer supplemental benefits that are not directly related to medical services.
Initially, CMS allowed the plans to provide “medically tailored meals,” which are healthy meals prepared for people with advanced and costly diet-related conditions such as diabetes, heart failure, end-stage kidney disease, and cancer. Usually delivered to patients at home or in group settings, these meals are designed to nourish people who have been recently discharged from the hospital and, in most cases, are provided for only a few weeks.
Just 336 Medicare Advantage plans will offer medically tailored meals as a supplemental benefit next year, a drop of 27% from 2023. These are far fewer plans than are offering the produce prescription benefit.
Gretchen Jacobson, PhD, the vice president of the Medicare program at the Commonwealth Fund, noted that the fruit and vegetable benefit is relatively easy for people to use.
“It usually involves a debit card, so it’s readily accessible to them to use when they go to the store,” she said.
In addition, a produce prescription benefit applies to a much larger group of people than does the medically tailored meals benefit, which is mainly for very sick people, said Dariush Mozaffarian, MD, a cardiologist who is director of the Food Is Medicine Institute at Tufts University.
“Produce prescriptions are used in a less sick population,” he said. “They’re not so sick that they can’t shop and cook. They’re able to buy produce and prepare meals.”
The Medicare Advantage supplemental benefit that became effective in 2020 went beyond medically tailored meals and allowed plans to cover food and other supports for chronically ill patients such as transportation, air quality equipment, pest control, and home medications. To qualify for these benefits, a Medicare beneficiary must have one or more serious chronic conditions, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination.
Significantly, these criteria do not include food insecurity; a Medicare Advantage plan member does not have to be low-income to qualify. This is true of many food as medicine programs, noted Mozaffarian.
“It’s not necessarily tied to social needs,” he said. “It’s first and foremost tied to a disease treatment. While some [food as medicine] programs have also focused on social needs such as food insecurity, housing problems, and lower income, not all of them have.”
Why Are Insurers Doing This?
A 2019 Urban Institute paper suggested that Medicare Advantage insurers weren’t convinced that social determinants of health benefits, including food coverage, could save money. They were also concerned that investing in them might detract from other, more popular benefits. So why have they changed their tune on food is medicine?
It’s possible that some Medicare Advantage plans view produce prescription benefits as another way to attract and retain enrollees, Jacobson said. But they have to show it improves health, she noted.
David Muhlestein, PhD, a visiting policy fellow at the Duke-Margolis Center for Health Policy and formerly chief research and innovation officer at Health Management Associates, agreed with Jacobson that health plans are always looking for ways to distinguish themselves from traditional Medicare, and this might be one way to do it.
Beyond that, he said, “these food programs have shown promising results in some studies, which suggests that they may be a mechanism to reduce the medical cost of care. I think Medicare Advantage plans are hungry for ways to reduce their medical spend via non-medical interventions."
Two leading insurers, Humana and Elevance, explained why they’re providing medically tailored meals and grocery allowances to some of their members.
Humana said it offers its Healthy Options Allowance to eligible members in “chronic condition special needs plans” and to certain Medicare Advantage plan members. The allowance of up to $325 a month helps members pay for “essential living expenses,” including groceries, rent and utilities, and over-the-counter drugs.
According to a Humana spokesman, this program is “designed to provide assistance for certain Medicare Advantage members to address health-related social needs, which can help reduce stress and contribute to an overall healthier life – both mentally and physically.”
Elevance Health plans to “offer both nutritious meals and grocery allowances to many members to help them access healthy food,” an Elevance spokesman said. This includes a “post-discharge meal benefit … our grocery and healthy meal benefits provide [healthy food] access to many of our chronically ill members.”
Both Humana and Elevance focus especially on members who are dually eligible for Medicare and Medicaid. Noting that many of these low-income people live in “food deserts,” the Elevance spokesman said, “providing support to access meals and groceries allows our members to prioritize their health expenses and also alleviates the tough choice many face of going to the doctor or paying for necessities like healthy food.”
Early Research Is Promising
Some studies on the impact of medically tailored meals have shown positive results for people with diabetes, heart failure, HIV, AIDS, and chronic liver disease. There have also been a few studies on the outcomes of healthy food prescriptions.
The Geisinger Health Plan in Pennsylvania, for example, has found that providing fresh food to people with diabetes has a greater impact on their health than medications do. The health system “prescribes” food to some patients and their families, which they can buy at fresh food “farmacies” on hospital campuses or nearby. Over 4 years, Geisinger found, the average HbA1c levels of these patients dropped 2.4%, leading to a 27% drop in emergency room visits.
A study of produce prescriptions by researchers at Tufts University showed no significant change in the mean HbA1c of its subjects, compared to controls, but it followed them for only 6 months during the COVID pandemic.
Mozaffarian told WebMD that a study – unpublished but presented by his team at a recent American Heart Association meeting – supports the use of these programs for low-income people with diabetes. While cost savings weren’t looked at, it’s known that health care expenses decrease for diabetes patients who lower their blood sugar, he noted.
National Modeling Studies
Mozaffarian’s team at Tufts has also done studies of both medically tailored meals and produce prescriptions. Their analysis shows that national use of medically tailored meals for patients with diet-related conditions and limited functional abilities could prevent 1.6 million hospitalizations and result in net savings of $13.6 billion in the first year.
The national use of produce prescription programs for U.S. patients with diabetes and food insecurity, the Tufts researchers calculated, could prevent 292,000 health events related to the heart and blood vessels, and add 260,000 quality-adjusted life years. But the cost of such a program would be slightly higher than the amount it would save in health care costs.
A recent re-analysis with updated population data, in contrast, shows that produce prescription programs could reduce health expenses, Mozaffarian said.
Studies are underway at Duke University and the University of Texas to further build the evidence foundation for food as medicine. In addition, Instacart, the online food delivery service, is involved in studies at four other universities.
Instacart Health has also formed food as medicine partnerships with Boston Children’s Hospital and Mount Sinai Solutions, the employer-facing division of the Mount Sinai Health System in New York, and the company is in talks with other health systems and payers to launch food as medicine programs, a spokesman said. In the Mount Sinai program, Instacart will offer $110 in fresh grocery “stipends” as a benefit for post-operative and post-partum patients insured by one of the division’s employer or union customers.